Sonoma Medicine Fall 2016

Volume 67, Number 4

Fall 2016 $4.95

EPIDEMIOLOGY

Advancing the practice of good medicine.

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Volume 67, Number 4

Fall 2016

Sonoma Medicine The magazine of the Sonoma County Medical Association

FEATURE ARTICLES

Epidemiology

5 7 11 15 17 19

EDITORIAL

Bending the Curve

“There is one important statistic that is often overlooked: Even with all these ailments, our life span is longer today than ever.”

Sanjay Dhar, MD

Page 21: Kalaupapa

INFECTIOUS DISEASE

Zika and Other Emerging Arboviruses

“The introduction of locally transmitted Zika virus into the United States has highlighted the distress that an epidemic of an untreatable, vector-borne and sexually transmitted disease can create.”

Kenzie Gardner, BSN, RN, Dale Westrom, PhD, MD

HIV/AIDS UPDATE

Ending the HIV Epidemic in Sonoma County

“Thirty five years into the HIV/AIDS epidemic, we have an unprecedented opportunity to end HIV transmission in Sonoma County.”

Danny Toub, MD, AAHIVS

DIABETES PREVENTION

Stemming the Tide

“If you think diabetes mellitus is a scourge on our population, you are in good company.”

Jerome Minkoff, MD

Page 27: Treating macular degeneration

HEROES FOR HEALTH

Building the New

“Why does chronic disease have to be an enemy that is always pushing us back?”

Andrew Luckett, MD

SONOMA COUNTY DHS

Public Health Epidemiology

“The demand for high-quality, cross-sector health data continues to grow in Sonoma County.”

Sarah Katz, MPH, Jamie Klinger, MA, Jenny Mercado, MPH, Lucinda Gardner, MSPH, Karen Holbrook, MD, MPH, Brian Vaughn, MPH Table of contents continues on page 2.

Cover: Aedes aegypti, a mosquito that transmits Zika, dengue and chikungunya viruses. Photo by Muhammad Mahdi Karim.

Sonoma Medicine DEPARTMENTS

21 27 33 37 41 44

MEDICAL HISTORY

Last Cries of Kalaupapa

“The epidemic started in typical fashion. Except for a time factor of months, instead of days, the sharp upward slope of beginning cases could have been ebola, Zika or smallpox.”

T.W. Hard, MD

LOCAL FRONTIERS

Anti-VEGF Treatment for Exudative Macular Degeneration

“The advent of intravitreal anti-VEGF injections revolutionized the treatment of exudative AMD. These treatments preserved and often improved vision and quality of life for patients.”

Shalini Yalamanchi, MD, Stephen Meffert, MD

GIVE-A-GIFT

Empowering Lives One Computer at a Time

“By continuing their education past high school, foster youth have the best chance of success—and laptop computers are essential tools for that success.”

Laura Robertson

CURRENT BOOKS

Boo Radley, Block Parties and World Peace

“Khanna suggests that international ‘bloc parties’ could build prosperous new trade groups like the EU that could peacefully unite all of the Americas or all of Asia in new, win-win relationships.”

Brien A. Seeley, MD

Board of Directors

Regina Sullivan, MD President Peter Sybert, MD President-Elect Brad Drexler, MD Treasurer Patricia May, MD Secretary James Pyskaty, MD Board Representative Mary Maddux-González, MD Immediate Past President Rick Flinders, MD Margaret Gilford, MD Len Klay, MD Marshall Kubota, MD Clinton Lane, MD Karen Milman, MD Rob Nied, MD Richard Powers, MD Rajesh Ranadive, MD Jan Sonander, MD Jeff Sugarman, MD

Cynthia Melody

Subterranean Homesick Bells

“I don’t know about you, but I found kindergarten to be a jarring and unexpected interruption of my chosen lifestyle.”

Rick Flinders, MD

WORKING FOR YOU

Your Voice for Change

“When you join SCMA, your voice gets amplified and becomes a strong catalyst for change.”

Regina Sullivan, MD SCMA

2016

PAGE 32 2 Fall 2016

Mission: To enhance the health of our patients and community; promote quality, ethical health care; and foster strong patient-physician relationships and the personal and professional well-being of physicians through leadership, partnership and advocacy.

Staff

PERSONAL HISTORY

41 New Members Classifieds 43 Ad Index

SONOMA COUNTY MEDICAL ASSOCIATION

Executive Director Rachel Pandolfi Executive Assistant Linda McLaughlin Graphic Designer Susan Gumucio Advertising Representative Steve Osborn Managing Editor Alice Fielder Bookkeeper

Membership

Active members 610 Retired 224 2312 Bethards Dr. #6 Santa Rosa, CA 95405 707-525-4375 Fax 707-525-4328 www.scma.org

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Value of Membership PRACTICE

PROFESSIONAL

Sonoma Medicine Editorial Board

PERSONAL

Membership in SCMA means real participation in the political discussion.

Together we can protect our value as physicians, build a more stable and prosperous practice, and promote a healthier community.

REGINA SULLIVAN, MD Obstetrics & Gynecology SCMA President regina.t.sullivan@kp.org 393-4081

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36

Why PHYSICIANS PRACTICING IN SONOMA COUNTY should be SCMA/CMA members:

1

By speaking with a united voice, physicians exert a powerful influence on the political process at the local, state and national levels. Organized medicine is the “one voice” that legislators and government hear.

2

SCMA and CMA have worked diligently to protect MICRA (California’s Medical Injury Compensation Reform Act), spearheading a successful campaign to defeat the anti-MICRA Prop. 46 in the 2014 election.

3

SCMA is involved in several initiatives to improve community health in Sonoma County, such as increasing access for the uninsured; supporting anti-tobacco, oral health and end-of-life initiatives; reducing cardiovascular risk; and promoting safe prescribing of opiates.

4 Fall 2016 Join SCMA/CMA Now!

• 707-525-4375 •

Jeff Sugarman, MD Chair Allan Bernstein, MD James DeVore, MD Rick Flinders, MD Rachel Friedman, MD Brien Seeley, MD Mark Sloan, MD Regina Sullivan, MD

Staff Steve Osborn Editor Cynthia Melody Publisher Linda McLaughlin Design/Production Susan Gumucio Advertising Sonoma Medicine (ISSN 1534-5386) is the official quarterly magazine of the Sonoma County Medical Association, 2312 Bethards Dr. #6, Santa Rosa, CA 95405. Periodicals postage paid at Santa Rosa, CA, and additional mailing offices.

POSTMASTER: Send address changes to Sonoma Medicine, 2312 Bethards Dr. #6, Santa Rosa, CA 95405.

Opinions expressed by authors are their own, and not necessarily those of Sonoma Medicine or the medical association. The magazine reserves the right to edit or withhold advertisements. Publication of an ad does not represent endorsement by the medical association. Email: scma@scma.org.

The subscription rate is $19.80 per year (four quarterly issues). For advertising rates and information, contact Susan Gumucio at 707525-0102 or susan@scma.org.

www.scma.org

Printed on recycled paper. © 2016 Sonoma County Medical Association

Sonoma Medicine scma@scma.org

EDITORIAL

Bending the Curve Sanjay Dhar, MD

N

ews outlets and social media are constantly screaming at us about obesity statistics showing that nearly two-thirds of adult Americans are at an unhealthy weight.

These statistics could be the cornerstone of a national campaign to get Americans to eat healthier and exercise more, but that is not the case, given the increased incidence of hypertension, diabetes and other chronic ailments. In spite of this depressing situation, there is one important statistic that is often overlooked: Even with all these ailments, our life span is longer today than ever.

Thanks to advances in medicine, especially in the field of cardiology, people are living longer with chronic diseases. Below are several case scenarios that would formerly have led to premature death.

Heart attack and heart disease are still the No. 1 killers of Americans, but advances in managing acute heart attack in all age groups, innovations in delivery technology, and increased speed of care coordination have led to fewer long-term comorbidities and subsequent complications. It’s not surprising for a patient presenting at the emergency department with a heart attack to be back on a golf course within a week.

Pacemaker implantation in patients with complete heart block has seen remarkable innovation in recent years.

Without a pacemaker, patients in complete heart block may be extremely Dr. Dhar is a Santa Rosa cardiologist.

Sonoma Medicine

limited in their daily activities or even be deceased. The next generation of miniature, leadless, longer-lasting and MRI-compatible implants will take cardiac rhythm management to a higher level.

Implantable cardioverter-defibrillators in patients with sudden cardiac death have improved by leaps and bounds. Life after a sudden cardiac death experience is fraught with constant fear of the next event. ICDs have taken that fear away. Further, miniaturization of the bulky devices has led to their use with even our frailest patients. Advances in the field of electrophysiology have allowed surgeons to implant these devices prophylactically in patients who are at the greatest risk of having a major cardiac event.

Valve replacement used to require an open-heart procedure, which is quite dangerous for very sick and very old patients. With the arrival of transcatheter aortic valve replacement (TAVR) and implantation (TAVI), these patients have received a new lease on life. The minimally invasive TAVR procedure, similar to putting a stent in the coronary artery, repairs the aortic valve without removing the old, damaged valve. Instead, it wedges a replacement valve into the aortic valve’s place to help remove the restriction of blood flow from the left ventricle. I have witnessed several TAVR success stories, including a 97-year-old patient of mine who was in severe endstage heart failure but went line dancing one week after getting a TAVR. The

advances in minimally invasive cardiac surgery will extend to other fields in medicine and ultimately result in a more humane way of dealing with severe clinical situations.

A left ventricle assist device (LVAD) can be attached to the heart to help people whose hearts are too weak to pump blood. LVAD is usually reserved for end-stage heart failure when all other therapies have failed. Some patients use LVADs while awaiting heart transplant surgery. This use is called “bridge to transplantation.” Patients who aren’t eligible for heart transplant surgery may still benefit from an LVAD by keeping it for the long term. This use is called “destination therapy.”

Heart transplants are the ultimate surgical maneuver and are now performed routinely, with longer survival data, to help prolong precious human life. Transplants have also led to significant improvements in chronic immunosuppression therapy to avoid transplant rejection.

These scenarios wouldn’t be possible without the hundreds of thousands of scientists, researchers, biomedical engineers, entrepreneurs and dreamers who have worked behind the scenes to bend the curve in spite of all the odds stacked against us. The next generation of advances in nanotechnology, genetics and stem-cell therapy will continue to make lives better for all of us.

Email: sdhar@northbaycardiology.com

Fall 2016 5

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INFECTIOUS DISEASE

Zika and Other Emerging Arboviruses Kenzie Gardner, BSN, RN, Dale Westrom, PhD, MD

T

he i nt roduc t ion of lo c a l ly transmitted Zika virus into the United States has highlighted the distress that an epidemic of an untreatable, vector-borne and sexually transmitted disease can create. This distress is similar to that caused by the recent ebola and avian influenza epidemics in other parts of the world.

Although certain diseases (including ebola and avian influenza) have a low probability of affecting people living in the United States, other viruses borne by arthropods (arboviruses) are emerging in the U.S. and may affect Sonoma County and the rest of California.

Local residents already encounter risk by traveling to areas where arboviruses, especially those borne by mosquitos, are actively spreading. Infected travelers can further transmit the virus to their sexual contacts and transplacentally to their unborn babies.

Mosquito-borne infections in North America are rare. The least rare is West Nile virus, followed by the viruses for eastern equine encephalitis, western equine encephalitis, St. Louis encephalitis and LaCrosse encephalitis. Since 2003, more than 5,700 cases of West Nile virus have been reported in California.1 Ms. Gardner is a doctoral candidate in nursing at Duke University; Dr. Westrom is a Santa Rosa dermatologist with a doctorate in parasitology and a special medical interest in travel medicine.

Sonoma Medicine

Sonoma County had one case in 2005 and one in 2007, but none since.2 In recent years, however, new arboviruses have emerged in North America that could result in significant human morbidity and mortality. These include the chikungunya, dengue and Zika viruses. Only a few travel-associated arbovirus infections have been reported in Sonoma County residents, but the emergence of new arboviruses increases the risk of locally transmitted disease and warrants further education on the topic. This article focuses on epidemiology, clinical manifestations, treatment and prevention of these viruses.

Epidemiology

There are four main families of arboviruses: Togaviridae, Flaviviridae, Benyaviridae and Reoviridae. Arboviruses require an arthropod vector— such as a mosquito, tick or sandfly—to facilitate transmission, which often occurs in areas conducive to arthropods.3 Of note, the increasing number of mosquitos in Sonoma County is attributed to warmer weather and extreme drought followed by flooding.4 Many arboviruses are zoonotic (having animal reservoirs) although some can be transmitted directly among humans. Factors contributing to the emergence of arboviruses include globalization, increases in plant and animal transport, human travel, population density, arthropod dispersion, and virus mutation.5

Over 300 types of mosquitos (family Culicidae) are capable of transmitting arboviruses. West Nile virus is transmitted by mosquitos in the Culex genus, but chikungunya, dengue and Zika viruses are transmitted by mosquitos in the Aedes genus.6 Aedes mosquitos, in particular A. aegypti and A. albopictus, are fierce daytime biters, compared to the Culex mosquitoes, which prefer to bite at dawn or after dusk.7 Although Culex mosqu itos a re com mon i n Sonoma County, neither A. aegypti nor A. albopictus have been detected here.

However, A. aegypti has been detected in both Alameda and San Mateo counties.8 Mosquitos in the Aedes genus are established in many counties in central and southern California. They adapt well to peridomestic environments and have become resistant to conventional spraying in some parts of the world.9 It is possible that invasive Aedes mosquitos will be introduced into Sonoma County and become established.

Dengue virus (family Flaviviridae) is mainly spread by A. aegypti and is the most common arbovirus worldwide (the most common in the U.S. is West Nile). Forty percent of the global human population is at risk of transmission, and between 50 and 100 million people are infected with dengue virus every year.10 Dengue is endemic in more than 100 countries, mainly in South Asia, Southeast Asia, Central America and South America. More than 260 confirmed Fall 2016 7

cases of dengue were reported in the where four people acquired the disease to distinguish because the human 21 Hawaiian Islands from fall 2015 to spring in Miami-Dade County. The total of host can have a range of nonspecific, 2016.11 In California, more than 100 cases locally transmitted Zika cases in Florida subclinical to severe symptoms (Table of travel-associated dengue have been is now more than 40.22 In August, the 1). Thus it is invaluable to conduct reported so far this year, including four U.S. Department of Health and Human thorough travel, environmental expo12 in Sonoma County.

Services declared a public health emersure and sexual histories on every Chikungunya virus (family Togagency in Puerto Rico when 1,914 new patient with possible arbovirus expoviridae) is transmitted by both A. aegypti cases were reported in one week, for a sure. Arborvirus infection should be and A. albopictus. Animal reservoirs total of 10,690 cases since the first one added to the differential diagnosis for 23 include monkeys, birds and rodents. was reported in December 2015. travel-related diseases, including fever, Chikungunya underwent a mutation Many factors (including failure to malaria and typhoid. Patients presentin 2005, enhancing its geographic diagnose or misdiagnosis) contribing with fever, rash, conjunctivitis, spread and ability to infect humans.13 ute to worldwide underestimation of arthralgia, myalgia, headache, hemorAn estimated 3 million chikungunya arbovirus incidence, prevalence and rhage and/or shock should be evaluated infections occur worldwide each year.14 disease burden. Access to health care for an arbovirus infection, especially if The first locally transmitthey have recently traveled ted case of chikungunya in to an endemic area or have Table 1. Clinical Manifestations of the U.S. occurred in Florida had contact with someone Zika, Dengue and Chikungunya in 2014.15 Fifteen cases of who has traveled to an

Zika Dengue Chikungunya travel-associated chikunendemic area. gunya have been reported Patients with dengue Conjunctivitis ✔ in California so far this may exhibit fever, rash, Congenital year, but none in Sonoma arthralgia, myalgia, head✔ Abnormalities County.16 ache, hemorrhage and/or Z i k a v i r u s (f a m i ly shock. A fever is characteris Neurologic ✔ Complications Flaviviridae) is also transtic of dengue and may vary mitted by A. aegypti and from low grade to 105° F. Arthralgia/Myalgia ✔ ✔ ✔ A. albopictus. Zika was Children may experience Headache ✔ ✔ ✔ originally isolated from febrile seizures. Severe a rhesus monkey in the thrombocytopenia, hemor Fever ✔ ✔ ✔ Zika Forest of Uganda in rhage and shock are char Hemorrhage/Shock ✔ 1947, and the first human acteristic of severe dengue infected by the virus was a disease.25 Rash ✔ ✔ ✔ young Nigerian female in The word chikungunya 1954.17 We are still learning originated in Tanzania and about Zika, including routes and other resources, standardized testing, and means “to become contorted” because parameters of transmission. Zika has means of documentation and reporting the disease typically causes debilitating been identified in multiple body fluids are necessary for proper identification arthralgias (without arthritis) that are (e.g., blood, urine, semen, vaginal fluids, and prevention of arboviruses. accompanied by acute fever. Usually saliva), some for prolonged periods (e.g., Dengue, chikungunya and Zika are the virus is self-limiting, but severe, semen). Zika is transmitted transplatransmitted from similar vectors, which atypical cardiac and neurologic presencentally and is the only known arboallows for co-circulation and co-infectations of the disease were observed virus that can be transmitted through tion. A recent case report described a during a 2005-06 epidemic in Réunion, sexual contact.18 pregnant woman in Colombia who was an island in the Indian Ocean.26 The FDA recently recommended co-infected with dengue, chikungunya The exact incubation period of Zika 24 testing all donated blood for Zika. So and Zika. Also, the varying durations is unknown but is proposed to be a few far this year, more than 2,250 travelof viremia and viruria and serologic days to two weeks. As with West Nile associated Zika cases and more than 20 cross-reactivity among flaviviruses (e.g., virus, approximately 80% of infected sexually transmitted Zika cases have dengue, Zika, yellow fever, Japanese patients will not recognize symptoms.

19 been confirmed in the United States. In encephalitis virus) significantly compliTypical symptoms include fever, macuCalifornia, 260 travel-associated cases of cate testing and interpretation of tests. lopapular rash, conjunctivitis, myalgia, Zika virus have been reported this year, arthralgia, fatigue and headaches.27 The 20 including five in Sonoma County. In Clinical Manifestations presence of conjunctivitis may help to July, the first locally transmitted cases Clinical manifestations of dengue, differentiate Zika from dengue and in the U.S. were reported in Florida, chikungunya and Zika are difficult chikungunya. Symptoms commonly last 8 Fall 2016

Sonoma Medicine

2–7 days, but Zika in pregnant women is a public health concern because of complications, especially those impacting pregnancies and fetal health.

Zika infections during pregnancy can cause birth defects and other serious brain anomalies. The reported spectrum of adverse events includes pregnancy loss, microcephaly, brain and eye abnormalities, poor intrauterine growth, and placental insufficiency.

Late sexual transmission of Zika is related to the persistence of virus in semen for up to six months.28 The risk of Zika virus to pregnant women and the possible routes of exposure (e.g., travel to areas with active transmission, sexual contact with travelers) should be communicated to all pregnant women and to all women of childbearing age who are engaging in sexual intercourse, along with their spouses or partners.

Guillain-Barré syndrome and other neurological complications have also been reported in Zika.29 If patients in Sonoma County have symptoms suspicious of Zika or another arbovirus and have been in an endemic area or had sex with an exposed partner, blood and urine specimens should be collected within 21 days of symptom onset. All asymptomatic pregnant women who have traveled through a Zika-endemic area or had sex with an exposed partner should also be tested.

The Sonoma County Public Health Disease Control Unit (707-565-4566) should be contacted immediately to report exposures and discuss appropriate testing for the patient. Commercial testing for Zika is underway but not yet available.

Treatment and Prevention

Only limited therapies are available for dengue, chikungunya and Zika.

Instead, recent research is focused on vector management and supporting the development of a Zika vaccine. A current trial of a genetically engineered male A. aegypti has been developed to sterilize female mates and subsequently lower the mosquito population.30 The trial is controversial because of the unknown long-term environmental Sonoma Medicine

impact on mosquitos and other species.

The latest estimates push the timeline for development of a vaccine to 2018.31 Preventing contact with mosquitos is key to limiting the spread of arboviruses. If possible, it’s best to stay indoors and avoid vector breeding areas, such as stagnant water. When going outdoors, cover skin with clothing and apply DEET insect repellent to exposed areas. People traveling to endemic areas should take extra precautions. Pregnant women are advised not to travel to Zika-endemic areas or impacted areas of Florida.32 If an arbovirus is suspected, aspirin and NSAIDs should be avoided to prevent hemorrhagic events in dengue and Reye’s syndrome in children.

Goals for Clinical Practice: Arbovirus The following goals are intended to enhance clinical awareness of emerging arboviruses:

Conclusion

Zika, chikungunya and dengue are emerging rapidly worldwide. Sonoma County residents are at risk for viruses through travel and (with Zika virus) sexual contact with travelers. In time, the county may also face the risk of locally transmitted arboviruses.

Only limited therapies are available to treat or prevent disease caused by arboviruses. Basic awareness of the epidemiology, clinical manifestations, treatment and prevention of emerging arboviruses is vital to preventing local transmission of these diseases. (Clinical practice goals for arbovirus are shown in the sidebar.)

Emails: kenzieagardner@gmail.com, drwestrom@sbcglobal.net

Stay abreast of current news and evidence-based research on the emergence of arboviruses, including geographic locations of active disease transmission.

Know how to identify symptoms associated with an arbovirus infection.

Report possible arbovirus infections to the Sonoma County Public Health Disease Control Unit (707-565-4566).

Encourage prevention strategies for all patients, especially those traveling to endemic areas.

Ask patients to visit these websites for information on arboviruses: • sonomacounty.ca.gov/health/ Zika-virus • www.cdph.ca.gov/HealthInfo/ discond/pages/Zika.aspx • www.cdc.gov/Zika/fs-posters Conduct thorough travel, environmental exposure and sexual histories on all patients and discuss current literature and recommendations with patients considering pregnancy.

Support the Marin/Sonoma Mosquito & Vector Control District.

Support ongoing research on emerging arboviruses, treatment therapies, and vector transmission control that does not harm animals or the environment.

Encourage global guidelines to monitor disease burden and establish standards of care.

The AlTschuler cenTer “THE DOCTOR IS IN.” You can count on me to personally:

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Fall 2016 9

References

1. CDPH, “Human West Nile virus activity, California, 2003-2016,” www.westnile. ca.gov (2016).

2. CDPH, “Reported human West Nile virus cases in California, by county, 20032011,” www.westnile.ca.gov (2012).

3. CDC, “Vector-borne diseases,” www. cdc.gov (2016).

4. Marin/Sonoma Mosquito & Vector Control District, “High abundance of mosquitos,” msmosquito.com (2016).

5. Liang G, et al, “Factors responsible for the emergence of arboviruses,” Emerg Microbes Infect, 4:1-5 (2015).

6. WHO, “Vector-borne diseases,” fact sheet 387, www.who.int (2016).

7. Miller E, “Mosquito genus and species,” www.mosquitoreviews.com (2012).

8. CDPH, “Aedes distribution map,” www. cdph.ca.gov/HealthInfo (2016).

9. Marcombe S, et al, “Insecticide resistance in the dengue vector A. aegypti,” PLoS One, 7:e30989 (2012).

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10. CDC, “Dengue,” www.cdc.gov (2014).

11. State of Hawaii, “Dengue outbreak, 201516,” health.hawaii.gov/docd (2016).

12. CDPH, “CDPH update on number of dengue infections in California,” www. cdph.ca.gov/HealthInfo (Sept 2, 2016).

13. Tsetsarkin K, et al, “A single mutation in chikungunya virus affects vector specificity and epidemic potential,” PLoS Pathog, 3:1895-1906 (2007).

14. Seppa N, “Chikungunya is on the move,” Science News (June 2, 2015).

15. CDC, “Chikungunya virus in the United States,” www.cdc.gov (2015).

16. CDPH, “CDPH update on number of chikungunya infections,” www.cdph. ca.gov/HealthInfo (Sept 2, 2016).

17. Musso D, Gubler D, “Zika virus,” Clin Microbiol Rev, 3:487-521 (2016).

18. CDC, “Zika and sexual transmission,” www.cdc.gov (2016).

19. CDC, “Zika virus disease in the United States, 2015-2016,” www.cdc.gov (2016).

20. CDPH, “CDPH weekly update on number of Zika virus infections,” www.cdph. ca.gov/HealthInfo (Sept 9, 2016).

21. CDC, “Florida investigation links four recent Zika cases to local mosquito-borne virus transmission,” www.cdc.gov/media (July 29, 2016).

22. CDC, “Zika case counts in the U.S.” www.cdc.gov (Sept 7, 2016).

23. “US declares state of emergency in Puerto Rico over Zika epidemic,” www. theguardian.com (Aug 12, 2016).

24. Villamil-Gomez WE, et al, “Zika, dengue and chikungunya co-infection in a pregnant woman from Colombia,” Int J Infec Dis, (July 17, 2016).

25. Senanayake K, “Dengue Fever,” BMJ, 315:h4661 (2015).

26. Busch M, “An overview of Chikungunya virus,” JAAPA, 28:54-57 (2015).

27. Coyle A, “Zika virus,” Nursing Crit Care, 11:30-34 (2016).

28. BBC News, “Zika found to remain in sperm for record six months,” www. bbc.com/news (Aug 12, 2016).

29. CDC, “Zika and Guillain-Barre Syndrome,” www.cdc.gov (2016).

30. Steenhuysen J, “U.S. one step closer to releasing engineered mosquito,” www. scientificamerican.com (2016).

31. Mukherjee S, “The chase: How fast can we roll out a Zika vaccine?” New Yorker (Aug 22, 2016).

32. Thompson D, “CDC: Pregnant? Avoid Miami Beach due to Zika,” www. webmd.com/news (Aug 19, 2016).

Sonoma Medicine

HIV/AIDS UPDATE

Ending the HIV Epidemic in Sonoma County Danny Toub, MD, AAHIVS Figure 1. Sonoma County AIDS Cases by Year of Diagnosis and Death, with Cumulative Prevalence

J

1000 900 800 700 600 500 400 300 200 100 0

Number

Year

or socio-economic circumstance, will have unfettered access to high quality, life-extending care, free from stigma and discrimination.”1 The World Health Organization has gone a step further by committing to ending the HIV epidemic by 2030. Their target for 2020 is that “90% of people living with HIV know their status, 90% of people living with HIV who know their status are receiving treatment, and 90% of people on treatment have suppressed viral loads.”2 Globally, HIV incidence began to decline in 1997, and the scale-up of antiretroviral treatment worldwide has been one of the greatest public health success stories over the last 20 years. Thirty five years into the HIV/AIDS epidemic, we have an unprecedented opportunity to end HIV transmission in Sonoma County, which has had an uncommonly high HIV prevalence for a U.S. rural or semi-rural area.3 After a decline from the peak of the AIDS epidemic

in the early 1990s, the annual number of newly diagnosed HI V i n fec t ion s i n Sonoma Count y remained relatively st able at approx imately 40 per year for close to a decade, but it appears that the number of newly diagnosed cases per year is declining again (Figure 1).

The county’s HIV epidemic has remained mostly among white men who have sex with men (MSM), who now have declining rates of HIV. In contrast, rates have been stable in women and in Latinos. The proportion of people with new HIV diagnoses in the county without a known or reported risk factor has tripled from 6% in 2000–2004 to 18% in 2010–2014.

Unlike the declining rates of HIV, rates of bacterial sexually transmitted infections (chlamydia, gonorrhea, and syphilis) have all been increasing in the last several years in Sonoma County.4 2014

2006

2002

1998

1994

1990

1986

Pre-1983

Dr. Toub is on faculty for the AIDS Education and Training Center and provides HIV consultation at Santa Rosa Community Health Centers.

Sonoma Medicine

936

2010

ose,” a 34-yearold man seen at a routine office v i sit, wa s due for regular diabetes lab monitoring. With a standing order, the me d ic a l a s s i st a nt adv i s e d h i m t h at he would be tested for HIV and that if he tested positive, treatment would be available. Routine antigen/antibody HIV testing confirmed HIV diagnosis in this asymptomatic patient, and he was rapidly linked to care with an HIV specialist. His wife, “Maria,” was identified as HIV-negative and placed on pre-exposure prophylaxis to prevent HIV acquisit ion. Jose currently has an undetectable HIV viral load and is taking one pill once daily for treatment. He and Maria are discussing plans to have an HIV-negative baby.

The most recent National HIV/AIDS Strategy for the United States offers this vision: “The United States will become a place where new HIV infections are rare and when they do occur, every person regardless of age, gender, race/ethnicity, sexual orientation, gender identity

Prevalence Diagnosed Cases Deaths

Antiretroviral Therapy (ART)

Morbidity and mortality from HIV have dropped precipitously since the advent of combination antiretroviral therapy (ART) 20 years ago. In addition to the personal health benefits of ART, lowering the community viral load by Fall 2016 11

expanding access to ART has profound implications for bending the curve to end the HIV epidemic. The most effective way to prevent the spread of HIV is to offer ART to all patients infected with HIV. Treatment lowers viral load, and less virus results in fewer new infections. This intuitively obvious statement has been validated: a recent randomized controlled trial of 1,763 sero-different couples, for example, showed that ART reduces HIV transmission by 93%.5 ART is currently recommended as soon as possible after HIV infection, regardless of CD4 count. The current standard of care in San Francisco is to begin ART within 24 hours after diagnosis.6 Nearly all newly diagnosed patients can be treated with one of the six different one-pill, once-daily fixed dose combinations approved by the FDA to treat HIV.7 About 90% of Sonoma County patients with HIV who are being treated with ART are fully suppressed (i.e., blood tests show no measurable virus).8 Universal viral suppression among people living with HIV can only happen if they are diagnosed, linked and retained in medical care.

Pre-exposure Prophylaxis (PrEP)

In addition to timely diagnosis and treatment of HIV-infected patients, new strategies target those at risk for acquiring HIV. Pre-exposure prophylaxis (PrEP) is an effective but underused tool that can be expected to help end the HIV epidemic. Treating high-risk

PrEP Providers and Consultants in Sonoma County Kaiser Permanente thrive.kaiserpermanente.org/care-nearyou/northern-california/santarosa/ departments/infectious-disease Planned Parenthood www.plannedparenthood.org/ health-center/california/santa-rosa Santa Rosa Community Health Centers www.srhealthcenters.org/vida West County Health Centers www.wchealth.org/service/hiv-services Bay Area & North Coast AIDS Education and Training Center bayareaaetc.org/contact-us

12 Fall 2016

patients with daily oral PrEP with the fixed-dose combination of tenofovir disoproxil fumarate (TDF) 300 mg and emtricitabine (FTC) 200 mg (Truvada) has proved safe and effective in reducing the risk of sexual HIV acquisition in adults.9 The FDA approved TDF/FTC in 2012 for PrEP, and the CDC guidelines recommend offering PrEP to patients in these high risk groups: men who have sex with men (MSM), adult injection drug users, and heterosexually active men and women who are at substantial risk of HIV acquisition.9 PrEP works extraordinarily well to prevent HIV (92% in MSM who adhere to treatment), compared to only 63–80% effectiveness for condoms.10 PrEP is prescribed using a well-defined protocol that includes close clinical followup and lab monitoring at least every three months to rule out newly acquired HIV infection. A new California law (AB 2640), still on the governor’s desk for signing as this article goes to press, will require medical care providers to give information about PrEP and other prevention and risk-reduction methods to patients who are at high risk for HIV but test negative for HIV infection.

Many people who can benefit from PrEP aren’t taking it. The CDC estimates that people at high risk who should be offered PrEP include about 1 in 4 sexually active gay and bisexual men, 1 in 5 people who inject drugs, and 1 in 200 sexually active heterosexual adults. In the U.S., patients with indications for PrEP include about 624,000 heterosexually active adults, 492,000 men who have sex with men, and 115,000 people who inject drugs.11 If more health care providers know about and prescribe PrEP, more HIV infections could be prevented. PrEP is fully accessible locally (regardless of insurance status) at Kaiser, Planned Parenthood, Santa Rosa Community Health Centers and West County Health Centers (sidebar). Additional resources include PleasePrEPMe.org and the Bay Area & North Coast AIDS Education and Training Center, which can help providers learn how to prescribe PrEP to keep their patients HIV-negative.

Universal Screening for HIV

With the availability of safe, tolerable, effective and accessible HIV treatment, the greatest risk to HIV-infected people is that their infection is not diagnosed. Medical providers are now charged with normalizing HIV testing and changing the culture so that all people age 15–65 know their HIV status.

For the past decade, the CDC has recommended one-time opt-out HIV screening for all adults,12 and annual screening for adults with risk factors. In 2013, the U.S. Preventive Services Task Force recommended that clinicians screen for HIV infection in adolescents and adults aged 15 to 65.13 Since 2014, California law (AB 446) has required that each patient who has blood drawn at a primary care clinic be offered an HIV test. Yet, despite all these evidence-based recommendations, many adolescents and adults in Sonoma County have not yet had an HIV test.

HIV testing of all adults can follow the precedent of normalizing HIV testing during prenatal care: nearly all pregnant women now get an HIV test during routine prenatal care. This wonderful success has nearly eliminated perinatal transmission of HIV in the U.S.14 As evidence, the most recent domestically acquired pediatric HIV infection in Sonoma County occurred in 2000.

Santa Rosa Community Health Centers is working hard to ensure that 75% of its patients older than 15 know their HIV status by the end 2017.15 As physicians move closer to eliminating HIV transmission in Sonoma County, they will need more resources to address social determinants of health and to test lower-risk populations. Widespread testing and linkage to care enables people living with HIV to access treatment early, and to reduce stigma.

Getting to Zero

Sonoma County can follow San Francisco’s lead on the path to “Getting to Zero”: zero new HIV infections, zero HIV deaths, and zero HIV stigma.16 This challenging work will involve case finding and surveillance, transmission interruption, systematic treatment and case management, and population-based Sonoma Medicine

monitoring.17 Opportunities to improve the HIV care continuum include diagnosing the undiagnosed, linking the diagnosed to care, retaining patients with HIV in medical care, and achieving viral suppression for patients living with HIV.18 A recent study estimated that more than 90% of HIV transmissions come from people who are either undiagnosed or diagnosed but not retained in medical care.19 Californians currently have a 1-in-102 lifetime risk of acquiring HIV, but disparities exist among risk groups.20 Half of black gay men and a quarter of Latino gay men, for example, are projected to be diagnosed within their lifetime. Focusing culturally competent treatment and prevention on our most vulnerable populations to achieve health equity is essential to ending HIV. Sonoma County has a long history of expertise in addressing the HIV epidemic and a strong collaboration among HIV experts. But HIV experts cannot do it alone: they need local primary care and specialist physicians to become involved in HIV testing and prevention in order to end HIV in Sonoma County. As described above, physicians should (1) offer ART to all patients infected with HIV, (2) identify patients at risk for HIV and offer PrEP as indicated and (3) test all patients 15–65 for HIV. If the use of HIV testing and prevention services continues to increase, patients like Jose and Maria will raise their children in a community without new HIV infections.

Email: dannyt@srhealthcenters.org

References

1. Office of National AIDS Policy, “National HIV/AIDS strategy for the United States: Updated to 2020,” www.aids.gov (2015).

2. UNAIDS, “On the fast track to end AIDS,” www.unaids.org (2016).

3. Eberle S, “Beyond the urban epidemic,” FOCUS: A Guide to AIDS Research and Counseling, 7;5 (1992).

4. Sonoma County DHS, “Annual report on HIV/AIDS in Sonoma County,” www. sonoma-county.org/health/publications (2015).

Sonoma Medicine

5. Cohen MS, et al, “Antiretroviral therapy for the prevention of HIV-1 transmission,” NEJM, 375:830-839 (2016).

6. Pilcher CD, et al, “Effect of same-day observed initiation of antiretroviral therapy on HIV viral load and treatment outcomes in a U.S. public health setting,”, JAIDS, e-pub ahead of print (July 16, 2016).

7. FDA, “FDA-approved HIV medicines,” aidsinfo.nih.gov (2016).

8. National Quality Center, HIVQUAL Sonoma Lake Mendocino Regional Group, unpublished data, www.incarecampaign.org (2016) 9. US Public Health Service, “Pre-exposure prophylaxis for the prevention of HIV infection in the United States,” www. cdc.gov/hiv (2014).

10. CDC, “Effectiveness of prevention strategies to reduce the risk of acquiring or transmitting HIV,” www.cdc.gov/hiv (2016).

11. CDC, “Estimated percentages and numbers of adults with indications for preexposure prophylaxis to prevent HIV acquisition,” MMWR (Nov 27, 2015).

12. Branson BM, et al, “Revised recommendations for HIV Testing of adults, adolescents, and pregnant women in health-care settings,” MMWR (Sept 22, 2006).

13. USPSTF, “HIV infection: screening,” www.uspreventiveservicestaskforce. org (2013).

14. CDC, “Diagnoses of HIV infection in the United States and dependent areas,” www.cdc.gov/hiv (2015).

15. Espinoza M, “AIDS, HIV infection drops again in Sonoma County,” Press Democrat (Dec 5, 2015).

16. www.gettingtozerosf.org.

17. Frieden TR, et al, “Applying public health principles to the HIV epidemic: How are we doing?” NEJM, 373:2281-87 (2015).

18. Office of AIDS, CDPH, “Continuum of HIV care in California,” www.cdph. ca.gov (2014).

19. Skarbinski J, et al, “HIV transmission at each step of the care continuum in the United States,” JAMA Int Med, 175:588596 (2015).

20. CDC, “Lifetime risk of HIV diagnosis in the United States,” www.cdc.gov (2016).

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Fall 2016 13

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DIABETES PREVENTION

Stemming the Tide Jerome Minkoff, MD

I

Table 1. Blood Test Levels for Diagnosis of Diabetes and Prediabetes

Fasting Blood Oral Glucose f you think diabetes • glucocorticoid excess

A1C Glucose Tolerance Test mellitus is a scourge • insulin resistance syn (percent) (mg/dL) (mg/dL) on our population, you drome Diabetes ≥6.5 ≥126 ≥200 are in good company. The Each component of the Prediabetes 5.7–6.4 100–125 140–199 AMA, the CDC and even insulin resistance syndrome Congress have endorsed the (also known as metabolic Normal ≤5.6 ≤99 ≤139 National Diabetes Prevensyndrome, dysmetabolic SOURCE: American Diabetes Association tion Program in an effort to syndrome or syndrome x) forestall worsening morbidincreases the risk of diabetes ity from diabetes mellitus (hereinafter complications such as retinopathy and and CV events.2 The components include referred to as “diabetes”). nephropathy are preventable with good obesity, high triglycerides, low HDL, Diabetes is on the rise. The genetic glucose control, so identifying patients hypertension and glucose intolerance determinants of diabetes are complex, with diabetes is essential (Table 1). (prediabetes). Usually we decide on but development of overt diabetes The intravascular inflammation treatment with statins and ASA based is clearly correlated with obesity. As associated with insulin resistance and on CV risk according to ATP III guideobesity increases throughout the develtype 2 diabetes can result in atherolines,3 yet the CV risk calculators4 do not oped world, the prevalence of type 2 sclerotic complications independent of include all metabolic syndrome factors, diabetes comes along with it—a conseglucose levels. Increased free fatty acids, despite evidence that each increases quence of increased insulin resistance lipid abnormalities and abnormal clotrisk for CV complications. Even family associated with more adipose tissue. ting dynamics all make cardiovascular history of early MI is not included in the Sedentary lifestyle, increased caloric events more likely. risk calculator. This suggests that we intake and aging all contribute to insuWe can improve CV outcomes by should err on the side of treating with lin resistance. The pancreatic beta cells controlling hypertension in diabetic CV protective medications in those can supply more insulin for a while but, and other patients at high risk of CV patients on the borderline if they also at some point, the insulin secretion is events. Once diabetes is diagnosed, have prediabetes or family history of CV insufficient to maintain normal serum treatment with cardioprotective medicadisease or hypertriglyceridemia. glucose levels, resulting in the higher tions improves morbidity and mortality.

Other associated risks, such as microglucose levels associated with diabetes.

Treatment with aspirin, statins, ACE albuminuria and hyperuricemia, may The prevalence of diabetes in our inhibitors or ARBs can also markedly be harbingers of diabetes risk. Certain adult population has more than doubled improve outcomes in our highest-risk ethnic groups also have increased 1 over the past two decades. Twelve patients. diabetes risk, including Hispanics, percent of American adults have type Screening patients with annual fastPolynesians, African Americans, Native 2 diabetes, and by the time they are diaging glucoselevels is a cost-effective way Americans, and South Asians. nosed, 50% of those adults have signs or of determining whether they have predisymptoms of complications associated abetes or are developing type 2 diabetes. an we stem the tide of diabetes? with overt diabetes, such as microalbuStarting at age 40, patients with any of It is possible. Plenty of evidence minuria or neuropathy. Microvascular the following risks should be screened: shows that progression from prediabe• family history of type 2 diabetes tes to overt diabetes can be prevented.

Dr. Minkoff, an endocrinologist, recently re• history of gestational diabetes In one study, three years of an intentired from Kaiser Permanente Santa Rosa.

• polycystic ovary syndrome sive lifestyle intervention (including

C

Sonoma Medicine

Fall 2016 15

increased exercise and moderating weight loss, sustained over the year-long caloric intake) decreased the incidence program.7 These patients were able to of diabetes by 58% compared to placebo reduce portion size, increase physical intervention.5 In the same study, metactivity and endorse an improvement formin decreased incidence by 31% in their overall health. To refer patients, compared to placebo. Although the call 707-545-9622 or email nmartieffect of less stringent programs may novich@scfymca.org. A sliding scale be less impressive, the ability to prevent is available for patients with limited incident diabetes has been confirmed means.

6 in several other studies and programs.

The Center for Well-Being hosts diabePatients at risk for diabetes should tes prevention classes that have probe screened annually. Fasting blood duced similar results. Call 707-575-6043 glucose or HbA1c may be the easiest test. or visit norcalwellbeing.org to refer I prefer FBG because one can also deterpatients. mine triglyceride levels, an important Diabetes prevention classes for CV risk factor. Patients with FBG scores Kaiser members can be accessed on of 110–125 mg/dL and/or multiple risk line at kp.org. factors for diabetes should be counseled Identifying patients at risk for to lose weight through caloric restriction developing diabetes is the easy part. and increased exercise.

The difficulties arise due to patient There are many diabetes prevenphysician complacency. We need ease take a few minutes to familiarize yourself with and the Safe Medicine tion programs in Sonoma County for medicine to remind our patients how important sposal Program which offers free and convenient drop-off locations patients known to have prediabetes it is to take control of their risks and to Sonoma and Mendocino County residents. Inform your patients and or sufficient risk of diabetes.

These enroll in diabetes prevention programs stomers about this option before recommending other disposal methods programs require a referral from a of proven benefit. ch as the toilet or trash. physician and are quite successful.

Participants in the Sonoma County Email: drjrm51@gmail.com ccording toFamily the U.S. Foodprogram and Drugaverage Administration, drug take-back programs YMCA 3–5%

Responsible Medication Disposal

References

1. Minkoff J, “PHASE: Preventing heart attacks and strokes everyday,” Sonoma Medicine, 65;1:21-22 (2014).

2. Sattar N, et al, “Metabolic syndrome with and without c-reactive protein as a predictor of coronary heart disease and diabetes in the West of Scotland Coronary Prevention Study,” Circulation, 108:414-419 (2003).

3. National Heart, Lung and Blood Institute, “ATP III at a glance,” www.nhlbi. nih.gov (2001).

4. Am Coll Cardio, “ASCVD risk estimator,” tools.acc.org (2014).

5. Knowler WC, et al, “Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin, NEJM, 346:393-403 (2002).

6. Balk EM, et al, “Combined diet and physical activity promotion programs to prevent type 2 diabetes among persons at increased risk,” Ann Int Med, 163:437451 (2015).

7. Personal correspondence, Sonoma County YMCA (2016).

e the best option for medicine disposal*. The FDA also recommends that nsumers talk to their pharmacists when in doubt about proper disposal.

Responsible Responsible ResponsibleMedication Medication MedicationDisposal Disposal Disposal

esidents can drop off expired, unused, and unwanted medicine throughout onoma and Mendocino Counties free of charge.

Please Please Pleasetake take takeaaafew few fewminutes minutes minutestoto tofamiliarize familiarize familiarizeyourself yourself yourselfwith with withthe the theSafe Safe SafeMedicine Medicine Medicine r more information, including drop off locations and restrictions, please visit:free Disposal Disposal Disposal Program Program Programwhich which which offers offers offers free freeand and andconvenient convenient convenientmedicine medicine medicinedrop-off drop-off drop-offlocations locations locations toto toSonoma Sonoma Sonomaand and andMendocino Mendocino MendocinoCounty County Countyresidents. residents. residents.Inform Inform Informyour your yourpatients patients patientsand and and customers customers customersabout about aboutthis this thisoption option optionbefore before beforerecommending recommending recommendingother other otherdisposal disposal disposalmethods methods methods such such suchasas asthe the thetoilet toilet toiletoror ortrash. trash. trash.

www.safemedicinedisposal.org

According According Accordingtoto tothe the theU.S. U.S. U.S.Food Food Foodand and andDrug Drug DrugAdministration, Administration, Administration,drug drug drugtake-back take-back take-backprograms programs programs ttp://www.fda.gov/ForConsumers/ConsumerUpdates/ucm101653.htm are are arethe the thebest best bestoption option optionfor for formedicine medicine medicinedisposal*. disposal*. disposal*.The The TheFDA FDA FDAalso also alsorecommends recommends recommendsthat that that consumers consumers consumerstalk talk talktoto totheir their theirpharmacists pharmacists pharmacistswhen when whenininindoubt doubt doubtabout about aboutproper proper properdisposal. disposal. disposal.

Residents Residents Residentscan can candrop drop dropoff off offexpired, expired, expired,unused, unused, unused,and and andunwanted unwanted unwantedmedicine medicine medicinethroughout throughout throughout Sonoma Sonoma Sonomaand and andMendocino Mendocino MendocinoCounties Counties Countiesfree free freeofof ofcharge. charge. charge.

For For Formore more moreinformation, information, information,including including includingdrop drop dropoff off offlocations locations locationsand and andrestrictions, restrictions, restrictions,please please pleasevisit: visit: visit:

www.safemedicinedisposal.org www.safemedicinedisposal.org www.safemedicinedisposal.org * *http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm101653.htm *http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm101653.htm http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm101653.htm

16 Fall 2016

Sonoma Medicine

HEROES FOR HEALTH

Building the New Andrew Luckett, MD

R

ecently I ran the longest race of my life. It wasn’t a marathon, or even a half-marathon. Just a 5K, 3.1 miles. It was the Heroes for Health Fun Run, where kids wore capes and adults dressed like superheroes to raise money for the Northern California Center for Well-Being’s healthy living programs for children. Given that I had never run such a long race, I have to admit that part of me was intimidated.

Will I be able to do it? I haven’t even run this much on a treadmill, I thought.

Nevertheless, I committed myself to run the race because I believed in the importance of the Center for WellBeing’s goal.

As a resident and now a fellow in Sutter Santa Rosa’s family medicine residency, I’ve seen plenty of children who, according to statistics, will develop diabetes, high blood pressure and heart disease years earlier in their life than their parents and grandparents because they haven’t had the opportunity to learn how to live a healthy life. No one person is at fault here; this is a multifactorial problem. Nevertheless, the public health programs at the Center for WellBeing, including the Heroes for Health Fun Run, are just what is needed to help these kids.

So there I am, running next to my fiancée, a pediatrician who knows much more than I do about obesity in children and can run a lot farther too. I’m struggling not halfway through the race. My mind was so focused on the fear and Dr. Luckett, a family physician, is completing a fellowship in integrative medicine at the Sutter Santa Rosa Family Medicine Residency.

Sonoma Medicine

difficulty of finishing the whole thing that I began to believe I couldn’t do it.

My legs are tired, I thought. A little while later I began to fixate on the pain in my hip. With every step I was that much closer to quitting.

Then something changed. I was passed in the race by a girl who was maybe 10 years old. At first I felt guilty that I couldn’t even run as fast as a 10-year-old; but then I said to myself, That’s awesome. Look at her go. She is doing great. That was followed by, Hey! I’m doing it too. This is great. We are all out here doing something healthy for such a meaningful purpose. My entire race turned around. I finished under 30 minutes, which was better than my goal. And, as the name suggested, that last half was indeed a Fun Run. When I set out to write this piece, I began with the title “Fighting Chronic Disease.” This is a sentiment often heard within the health care field. “She is battling with cancer,” they say. “We can beat heart disease.” “He is struggling with quitting smoking.” All of these metaphors imply that there is a laboring effort against some kind of resistant force. Why does chronic disease have to be an enemy that is always pushing us back?

The term cardiovascular diabesity encompasses the disease process that more Americans, kids and adults, live with than any other. It includes coronary artery disease, hypertension, diabetes, obesity and high cholesterol. All of these problems stem from our lifestyle choices, such as the food we eat, the cigarettes we smoke, our activity or lack thereof, our sleep habits, and our stress levels.

In Dan Milman’s Way of the Peaceful

Warrior, the fictional Socrates says, “The secret of change is to focus all your energy not on fighting the old, but on building the new.” At first in the Fun Run, I spent much of my time worrying about the old and the fact that I had never run such a long distance before. Once I focused on the reality that just attending the run was a success—simply being part of an event with the aim of helping more children be healthy—I was able to finish faster than I had hoped when I set out at the beginning.

I think that same secret applies to the people of Northern California who want to live healthier lives and the health professionals who are working with them to achieve this objective. If you work in the health care field, try not to take the easy way out by avoiding the conversation with your patient or client about living well. Don’t wrestle against the disease. Instead, walk with them on their path and cheer them on with every healthy choice they make.

If you’re the one making the change, don’t focus on how hard it is going to be, how much extra work it takes to change your old behaviors. Rather think about the extraordinary improvements that can happen once you begin making different choices. It’s not about beating cardiovascular diabesity. It’s about building a new life full of joy, vitality and well-being.

Email: ajluck01@gmail.com A slightly different version of this article appeared in the Northern California Center for Well-Being newsletter earlier this year.

Fall 2016 17

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SONOMA COUNTY DHS

Public Health Epidemiology Sarah Katz, MPH, Jamie Klinger, MA, Jenny Mercado, MPH, Lucinda Gardner, MSPH, Karen Holbrook, MD, MPH, Brian Vaughn, MPH

E

pidemiologists play a key role in describing and investigating causes of disease in populations, identifying people who are at risk of disease, and determining how to control or stop the spread of disease.1 At the Sonoma County Department of Health Services (DHS), epidemiologists engage in a broad range of activities, including public health surveillance and epidemiological investigation, communication, consultation, and program and policy evaluation. Their mission is to gather, analyze and interpret comprehensive and relevant health data on Sonoma County residents, and to use that data and information to reduce morbidity and mortality, achieve health equity, and improve quality of life for those residents.

DHS epidemiologists regularly analyze and report on vital statistics, communicable diseases, hospital, and socio-demographic data. They also examine population-based surveys, such as data from the California Health The authors work for the Sonoma County Department of Health Services. Ms. Katz is an epidemiologist and health program manager; Ms. Klinger, Ms. Mercado and Ms. Gardner are epidemiologists; Dr. Holbrook is the deputy public health officer; Mr. Vaughn directs the health policy, planning, and evaluation division.

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Interview Survey and the California Healthy Kids Survey. When local data are not available, epidemiologists develop or use existing data collection instruments to inform public health practice or assessment. Two recent examples of primary data collection are the Farmworker Health Survey2 and the Assessment of Healthcare Access, Utilization, and Patient Experiences Among Sonoma County Adult Undocumented Immigrants and Their Children.3 DHS epidemiologists also collaborate with other agencies on a wide range of public health projects. For example, they are working with the DHS internal incident response team, local healt h part ners, and Marin Sonoma Mosquito and Vector Control to support Zika preparedness and response efforts. Earlier this year, they provided technical assistance on the Sonoma County Community Health Needs Assessment, a joint project that involved DHS and most of the county’s medical organizations. They also assist with the Hearts of Sonoma County hypertension control initiative and the Opioid Prescribing Guidelines Workgroup. These collaborative efforts have strengthened partnerships with the local medical community and have increased knowledge of the county’s health and health care needs through data and information sharing.

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ublic health epidemiology is a rapidly evolving field. “Big data,” c ha ng i ng healt h com mu n icat ion environments, growing expectation for “open data” and many other factors have expanded the epidemiologist’s scope of work beyond traditional analysis of disease risk factors and general public health surveillance.

Furthermore, advances in technology and information sciences—coupled with financial incentives for data r e p or t i ng a nd n ew s y st e m s for storing and monitoring health care data—have led to the development of integrated healt h in format ion systems, including growing adoption of electronic medical records. These changes afford great opportunities to epidemiologists, if appropriate methods for obtaining and making use of such data and information can be thoughtfully developed, tested and implemented.4 For all these reasons, DHS epidemiologists are focusing on data and information sharing across sectors and organizations in Sonoma County, while at the same time meeting the ethical and legal obligations to safeguard all health information as required by law.

Data and information sharing can help increase business efficiencies, improve health outcomes, reduce health disparities and lower health care costs.

Fall 2016 19

One example of data sharing across organizations is Project Nightingale, a program funded by local hospitals, Partnership Health Plan and DHS. The project makes 24-hour respite beds available to unsheltered patients who are discharged from a hospital but have nowhere to recover. DHS epidemiologists are working with several partners to assess the effect of Project Nightingale on subsequent emergency department visits and hospital admissions.

This type of evaluation can only be conducted by coordinating and sharing data across health and socialservice data systems that track hospital patients, the use of human and social services, and case management.

In July, DHS and local partners received funding to become an Accountable Community for Health (ACH). This initiative will help DHS create a more expansive, connected, coordinated and prevention-oriented local health system

Considering a residential treatment or outdoor program?

through partnerships with medical clinics, hospitals, nonprofits, schools and other agencies in Sonoma County.5 As part of the initiative, DHS will use what it has learned from data sharing to improve health outcomes, create greater equity, reduce cardiovascular disease risk factors and lower costs related to cardiovascular disease, a leading cause of morbidity and mortality in Sonoma County.6 DHS epidemiologists will work with community partners to support cross-sector sharing, analysis and reporting of valid data to inform clinical and community interventions, and to evaluate community efforts to improve cardiovascular health.

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Collaborating with referring professionals, Bob Casanova, Psy.D. is a nationally respected educational consultant who specializes in providing recommendations for students with special needs of an emotional, behavioral or psychological nature.

Bob travels extensively throughout the year and has personally toured over two hundred schools and programs. As a Licensed Marriage and Family Therapist, Bob credits his clinical training and experience in deepening his understanding of a student’s needs. Bob helps students and families dealing with issues such as: • Adoption/ • Self-harm • Depression attachment issues • Oppositional • Anxiety • Family conflict • Drug or alcohol and defiant • PTSD / trauma • Loss and grief abuse • Divorce • Social concerns • Autistic spectrum/NLD • Learning differences • School failure • Low self esteem or refusal Bob Casanova, Psy.D. Educational Consultant Licensed Marriage & Family Therapist License Number: LMFT 37137

707-544-7000 20 Fall 2016

1260 North Dutton Ave. Suite 175 Santa Rosa, CA 95401 drbob@bobcasanova.com www.bobcasanova.com

he demand for high-quality, crosssector health data continues to grow in Sonoma County. As the field of public health epidemiology evolves, DHS epidemiologists will continue to identify risk and protective factors for disease and well-being through traditional epidemiological methods, and to take advantage of new and emerging data opportunities. DHS will integrate these new sources of informat ion and k nowledge into effective interventions in partnership with the many residents, organizations a nd pol ic y ma k er s who work s o diligently to improve and protect individual and public health in Sonoma County.

Email: Sarah.Katz@sonoma-county.org

References

1. CDC, “Who are epidemiologists?” www. cdc.gov (2016).

2. Funded by the CDC; www.sonomacounty.org (2015).

3. Funded by Blue Shield of California Foundation; in press (2016).

4. Hiatt RA, et al, “Promoting innovation and creativity in epidemiology for the 21st century,” Ann Epid, 23:452-454 (2013).

5. “Health initiative awards $5.1 million in funding,” communitypartners.org (2016).

6. Kubu-Jones A, et al, “Building an accountable community of health in Sonoma County,” health.gov/news (2016).

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MEDICAL HISTORY

Last Cries of Kalaupapa T.W. Hard, MD

Father Damien’s grave on Kalaupapa (photo: T.W. Hard).

i.

Gentlemen, it’s the microbes who will have the last word.

—Louis Pasteur THE EPIDEMIC STARTED in typical fashion. Except for a time factor of months, instead of days, the sharp upward slope of beginning cases could have been ebola, Zika or smallpox. There were a few isolated patients at first, not enough to arouse the suspicion of local physicians or the health department. For the next several decades, the disease—thought to originate with Chinese immigrants— spread insidiously and quietly. Although Dr. Hard is an emergency physician at Petaluma Valley Hospital.

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the infection was disfiguring, deaths were rare. Often the first symptoms were little more than a small sore or patch of numbness, hardly enough to cause concern.

As the number of infected people increased, the medical director of a local hospital urgently requested the Board of Health “to devise some efficient and humane measure by which the isolation of those affected can be accomplished.“1 Ultimately, the Minister of the Interior issued the following proclamation: Whereas the disease has spread to considerable extent among the people and the spread thereof has excited wellfounded alarm . . . the Board of Health, and its agents, are hereby empowered to

assist in removing such persons to a place of isolation . . . for all patients considered infected or capable of spreading the disease.1

The date was 1865; the location, Hawaii; the disease, leprosy. ii.

And this was his kingdom, a f lowerthrottled gorge with beetling cliffs and crags on which f loated the blattings of wild goats.

—Jack London, “Koolau, the Leper” (1913) We are flying westward from Maui at an altitude of one thousand feet. The Pailolo Channel spreads below in a vast undulating blueness. Our transportation Fall 2016 21

Kalaupapa Peninsula (photo: T.W. Hard).

is a specially fitted helicopter with a plastic canopy for maximum viewing.

Behind the controls is an ex-military pilot, fresh from a tour in Afghanistan. My wife and I are in the backseat, eyes pressed to the windows. Postcard images surround us in every direction.

Ahead, tall green mountains rise abruptly from the Pacific. Scattered rain clouds cloak the upper peaks. Far to the west, a rainbow arcs through the mist.

Our destination is Kalaupapa, a remote peninsula on the island of Moloka’i.

For more than a century, victims of leprosy were identified, quarantined and herded to Kalaupapa to die. Since there was no cure for the disease, the peninsula was a one-way stop. Children were ripped from their families; mothers carried off; fathers captured at gunpoint and marched to the piers. A few defiant individuals refused to comply. When a bounty was placed on their heads, they were hunted down.

I have wanted to visit Kalaupapa for many years. I was a resident at Queen’s Hospital in Hawaii once, and a relative of Queen Kapiolani was a patient of 22 Fall 2016

mine. By the time I started my internship, a cure for leprosy had already been discovered; yet even then the locals were reluctant to speak about the stigmatized disease. If you were Hawaiian and had a relative taken to Kalaupapa, you buried it in your past. Names of quarantined patients were erased from the family tree. It was as if an infected family member never existed.

As we cruise along the north edge of Moloka’i, we pass over a tall, razorsharp ridge. Abruptly, our vista opens into one of the most spectacular views of the Pacific. Carpeted green cliffs rise two thousand feet above the ocean.

Guidebooks call these the tallest sea cliffs in the world. Here and there, a waterfall cascades downward in a thin filament of spray. Below us, a half-dozen sea birds glide. The white birds, the blue ocean and the covered green ridges compose a scene of breathtaking beauty.

We pass a lovely valley, a deep cleft cut sharply into the mountains. There comes another and then a third. The valleys are isolated and remote. A few Hawaiians lived here once, but the

valleys were not easily reached and existence then, even for these native peoples, was difficult. Here the winter storms were fierce and the summer sun merciless. There was no outward passage except by sea.

Ahead looms the peninsula of Kalaupapa, a six-mile tongue of land flowing outward from the striking cliffs. The setting is perfect for a penal colony. The nearly impassable cliffs guard the southern end of the peninsula, and the ocean blocks all other escapes. A single narrow path winds up through the cliffs, but the trail is easily guarded. If you were dumped here, as the early patients were, there was no way out.

As we approach the landing strip in the comfort of our helicopter, I wonder what it must have been like for those first unfortunate people who were quarantined here. Starting in 1866, they came by the boatload every few months. By the end of the first year more than 100 patients had arrived. By the end of the tenth year, the population had grown to 800.

The ship captains were deathly afraid Sonoma Medicine

of the disease. To go ashore risked the possibility of exposure. Sometimes patients were rowed onto a rocky beach. At other times, when the seas were rough or the weather inhospitable, they were shoved overboard. Those who were too sick to swim surely drowned.

Those who made it to shore had to fend for themselves.

In the beginning, there was no shelter, no food, no blankets, no place of refuge. After all, these were “Hawaiians,” the authorities claimed. These were people used to living off the land.

After landing, we watch our helicopter head back to Maui along the steep cliffs; then we walk toward the tiny terminal and wait for others who make up the morning tour. Some are flying in by prop plane from Oahu. A few have hiked down the cliff trail, which is billed as “3.6 miles and 26 switchbacks.”

Inside the terminal we are greeted by a sign: “Welcome to Kalaupapa.” There was a different message once. Long before helicopters and runways, early patients carved a greeting reminiscent of Dante’s Inferno: “Enter all you, who abandon hope.” iii.

And the leper in whom the plague is, his clothes shall be rent, and his head bare, and he shall put a covering upon his upper lip, and shall cry, Unclean, unclean.

—Leviticus, 13:45 In recent times, there has been much effort to rebrand the infection caused

by M. leprae after the bacterium’s discoverer, the Norwegian physician Gerhard Hansen. Yet, despite the cure of modern antibiotics, the word leprosy still connotes horror and repulsion.

The initial symptoms of Hansen’s disease often depend on host immunity and may involve a progression of disfiguring sores along the face, nose and ears.

A loss of movement of the eyelids leads to eventual blindness. The disease also attacks nerve endings in the hands and Sonoma Medicine

feet, and with the ensuing numbness come injuries and infections, resulting in the ultimate loss of fingers and toes. The incubation of M. leprae may range over a number of years. Spread is thought to be through repeated exposure to respiratory droplets or recurrent skin contacts.

M. leprae defies Koch’s postulates for identifying causative agents of infectious

Father Damien shortly before his death in 1889 (photo: William Brigham).

disease. It has yet to be grown in culture, and transfer of the mycobacterium to research animals seems to be limited to the footpads of mice. Armadillos are the only animals suspected of carrying the disease.2 Recent DNA mapping has done much to identify the molecular composition of M. leprae. Genetic typing suggests that as many as a quarter of the population of Northern Europe may have been exposed to Hansen’s disease by the 10th century. From these studies, it has been postulated that most Europeans have developed a 95% immunity.3 The Hawaiians, of course, had no such natural protection. As with smallpox,

cholera, tuberculosis and syphilis, the M. leprae infection brought to Hawaii by outsiders spread through the native population with disastrous results.

When patients began arriving in Kalaupapa in 1866, the causes of leprosy were unknown, and there was no treatment. Some physicians speculated that leprosy was the fourth stage of syphilis.

Immoral living, poor sanitary conditions, even hereditary components were considered sources of the infection.

During the first several years of the Kalaupapa colony, the conditions were primitive. Patients cast ashore had to make their way inland. Some of the survivors lived in caves. Others erected flimsy stick huts that blew away in storms.

There was no running water; the nearest stream was in the mountains two miles away. It was an easy distance, if you were fit, but early patients were often crippled and could not walk. Others could not use their fingers to carry containers or bowls. The inhabitants had few blankets and clothes. Infected children, orphaned from their families, were often forced to work as slaves.

Such was the setting in 1873 when the Catholic Church recognized a need for order and civility.

The conditions were so deplorable that the church asked volunteers to stay for only a limited period of time, promising they could rotate out if circumstances became intolerable. The first to enlist was a 33-yearold Belgian priest named Damien De Veuster. During his first weeks in the colony, he slept under a tree. One hundred and thirty six years later, Father Damien was canonized as a saint. iv.

He was a coarse, dirty man, headstrong and bigoted . . . and his relation with women and the leprosy by which he died should be attributed to his vice and carelessness.

—Rev. C.M. Hyde So wrote a Honolulu pastor to his San Francisco colleague Rev. H.B. Gage in 1889 to discredit Damien’s fame. Gage Fall 2016 23

subsequently published the letter in The Presbyterian newspaper, where it garnered nationwide controversy. In Damien’s defense, Robert Louis Stevenson published a scathing open letter to Hyde in 1890 that remains one of the fiercest rebuttals in literature. “Your letter,” wrote Stevenson, “is a document which, in my sight, if you had filled me with bread when I was starving, if you had sat up to nurse my father when he lay a-dying, would yet absolve me from the bonds of gratitude.” 3 Father Damien came to Kalaupapa in 1873, eight years after the beginning of the Hawaiian Quarantine. At the time of his arrival there was no law, little shelter and no social order.

Women were assaulted, the weak were robbed, and days were often spent in drunkenness and debauchery. Damien, in a kind and persuasive way, brought decency and religion to the colony. He tried to abolish alcohol and encouraged respect for women and children.

He procured blankets, clothes and construction materials from the government. Over the next decade he built several churches, a dormitory, a reservoir, an aqueduct system and many homes for the inhabitants.

He was known as a tireless worker and a strong advocate for his patients.

“We lepers,” he liked to say. He remained in Kalaupapa for the last 16 years of his life, eventually catching leprosy and dying from it. v.

I have seen the bad effect of forcible separation of the married companions. It gives them compression of the mind, which in some cases is more unbearable than the pain and agony of the disease itself . . .

—Father Damien (1886) There are 12 adults on our tour, but no children: the colony does not permit guests under 16 years old. Some on the tour have been to Kalaupapa before. It is a very special place, they tell us. There is a spiritual sense of beauty here.

We climb into a yellow school bus that looks like a relic from the 1940s.

Our guide is an athletic woman dressed in khaki shorts and hiking boots. She 24 Fall 2016

has climbed down the 3.6-mile cliff trail every week for the past decade, but this is her last month of work. In the days to come, she reports, the National Park Service will be taking over the tours.

There are many changes planned, and she worries about what the future will bring. As the old bus creeps along a paved road, we feel as if we are carried back in time.

Our first encounter with the past is a grass strip next to the road with hundreds of graves. Some are marked by simple white crosses, others by concrete blocks. Most of these memorials are from the early 1900s, decades after Father Damien arrived.

I think back to historical accounts I’ve read about various patients brought to Kalaupapa with early signs of leprosy.

One account tells of a young man with a degree in economics. His future was cut short when he discovered a red sore on his arm. In another case, a lovely Hawaiian woman in her twenties with a beautiful voice and a successful musical career was shipped to Kalaupapa after physicians noted a numb patch on her leg. Although most patients quarantined on the peninsula were Hawaiian, I remember the photo of a young Caucasian father surrounded by four daughters he was forced to leave.

I wonder if the graves of these patients are here; and I wonder about thousands of other patients imprisoned on the colony. How could they survive?

How could they go on living, knowing the horrible trajectory of their lives?

Our guide tells us that 8,000 people died here over the years. Sadly, there are only 1,500 graves. At first, the burials were in small, shallow, unmarked pits.

The soil was hard to dig, and often the graves were uprooted and desecrated by the domesticated pigs.

We travel into the small government settlement. Many simple, wooden buildings have been preserved as they initially stood. Social outcry, pleas from quarantined patients and a visit

by Queen Kapiolani in 1884 placed significant pressure on the Hawaiian government to construct reasonable facilities for the colony. A small hospital,

a bookstore, an administration building and a warehouse next to a concrete pier remain standing. These late 19th century improvements persist with little change.

We visit a church and the gravesite of Mother Marianne Cope, who arrived in 1888 with six other nuns, several months before Damien died. Along with Damien, she did much to improve conditions for the patients. The nuns were especially helpful for young girls, who were often the most vulnerable to the disease. Mother Marianne founded a dormitory that housed more than 100 orphaned girls by 1893. Despite their intimate work, none of the nuns ever developed Hansen’s disease. Mother Marianne was canonized in 2012. vi.

Father Damien stepped ashore from the boat.

He had his left foot bandaged. Naturally, I asked the father how he had hurt his foot.

And came the prompt answer: “I put my foot into the water. I did not feel the heat.”

Then he added with a touch of irony, “I think I have the disease.“ —Ambrose Hutchinson, Kalaupapa patient (1878) 5 We are standing next to the grave of Father Damien. A thin iron fence surrounds the site, which is marked by a tall marble cross. The memorial rests next to the first church Damien built.

We are told his body was returned to Belgium in 1933 but several fragments of his remains still reside here. Someone has hung a group of flowered leis on the fencing. The bright yellow petals have faded, and the old pandanus tree that provided shade and shelter for the first part of Damien’s stay is long gone.

Even after much research on Kalaupapa, the story of the leper colony is still hard to fathom. What is clear is that Damien came to this isolated peninsula and devoted his life to the betterment of its unfortunate inhabitants. The church he built stands, as does the reservoir, providing water with which he could bathe and cleanse the wounds.

We will be departing soon, riding our helicopter back to a comfortable hotel on Maui. We will leave this place to a far different world than those first Sonoma Medicine

St. Philomena, the first church built by Father Damien (photo: T.W. Hard).

few inhabitants found. As I gaze across the magnificent green cliffs and the ocean rolling toward the rocky shore, what is most impressive is the silence.

But it is a silence to the ear, and not the soul.

If you close your eyes and stand quietly, you can still hear faint voices in the wind; the cries reverberate across the cliffs from patients once imprisoned here. They are sounds of sorrow and separation and despair.

On the walls inside one of the buildings, photographs depict the facial disfigurement of patients before and after the discovery of the antibiotic dapsone in 1946. In each instance the recovery is remarkable. The disease was arrested, the sores improved, the infection no longer contagious. Eventually, M. leprae became resistant to the antibiotic, so triple therapy (dapsone, rifampin, and clofazimine) is now used.

In 1965, one hundred years after it began, the quarantine on Kalaupapa was finally lifted. Families could come Sonoma Medicine

and go as they pleased. Some of the patients left. A few traveled around the world to see places they had missed.

Others stayed. For many, it was the only home they had ever known.

At the time of this writing, there are still a handful of patients living on the peninsula. Most are in their seventies.

When they die, this dark chapter in Hawaiian history will close.

The government plans to create a special memorial soon. There is talk about erecting a circular structure with a large granite wall containing the chiseled names of all 8,000 patients who were quarantined here. The memorial is planned for a grassy space thought to contain 2,000 unmarked graves.

As we fly out of the peninsula and turn east, I look back and find the narrow lava beach, the rise of land, the faded white church that Damien built.

In my imagination, I can see a small dark figure dressed in a cassock and a black-brimmed hat, hurrying along the path, stopping here and there to

help sick patients lying on the ground.

He pauses once, stands up, and gazes in our direction. Did he know? Did he realize what relief of suffering he would bring? The sun strikes his back, and his shadow drifts halfway across the world.

Perhaps in this one instance Louis Pasteur was wrong. Perhaps humankind, through kindness and love, invention and science—not microbes—will have the last word.

References

1. Inglis K, Ma’i Lepera, U Hawaii Press (2013).

2. Truman RW, et al, “Probable zoonotic leprosy in the southern United States,” NEJM, 364:1626-33 (2011).

3. Zhahng FR, et al, “Genomewide association study of leprosy,” NEJM, 361:260918 (2009).

4. Stevenson RL, “Open letter to the Reverend Dr. Hyde of Honolulu” (pamphlet), Sydney Press (1890).

5. Law AS, Law HG, Father Damien: a Bit of Taro, a Piece of Fish, and a Glass of Water, IDEA Center (2009).

Fall 2016 25

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LOCAL FRONTIERS

Anti-VEGF Treatment for Exudative Macular Degeneration Shalini Yalamanchi, MD, Stephen Meffert, MD

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ge-related mac ular degeneration (AMD) is the leading cause of severe irreversible vision loss in adults worldwide over t he age of 60.1 The disease escalates with age and affects 14–24% of American adults aged 65–74; 35–40% of those aged 75–84; and nearly 50% of those 85 and older.2–4 AMD is a progressive and chronic disease that involves deterioration of the macula, which is located in the retina and is responsible for high-resolution central vision. The macula is 5.5 mm in diameter and contains the largest concentration of colorsensitive photoreceptors (cones) in the eye. Loss of macular function can produce central visual field symptoms that interfere with the ability to read, recognize faces and drive.

AMD occurs in non-exudative (dry) or exudative (wet) forms.

Non-exudative AMD is slowly progressive and characterized Dr. Yalamanchi and Dr. Meffert are Santa Rosa retinal specialists.

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Figure 1. Color fundus photograph of the left eye.

Non-exudative AMD with drusen, pigmentary mottling and mild atrophic changes.

by drusen, pigmentary changes and retinal atrophy (Figure 1).

Variable amounts of vision loss occur in non-exudative AMD. Exudative AMD is characterized by choroidal neovascularization, in which abnormal blood vessels from the choroid grow into the subretinal space.

These vessels are fragile and ultimately leak blood, fluid and lipid, which can lead to acute symptoms of distortion and central vision loss (Figure 2). Progressive growth of this neovascular network can lead to macular scarring, cell damage and permanent vision loss.

B

Figure 2. Color fundus photograph of the right eye.

Exudative AMD with choroidal neovascularization, subretinal hemorrhage and subretinal fluid.

efore 2004, patients diagnosed with exudative AMD could anticipate nearcertain vision loss. Treatments at that time were only able to slow the progress of the disease and not reverse its impact on visual function. In 2004, the approach to exudative AMD changed when the disease’s pathogenesis was linked to an overexpression of vascular endothelial growth factor (VEGF). The upregulation Fall 2016 27

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of VEGF in exudative AMD begins a series of events: (1) binding of VEGF to VEGF receptors on endothelial cells, (2) endothelial cell activation, (3) produc t ion of c ytok i nes t hat increase vascular permeability and lead to proliferation and migration of endothelial cells, (4) formation of vascular buds and then tubules that develop into vessels with the growth of surrounding pericytes. Inhibiting the effects of VEGF on this process stabilizes both choroidal neovascularization and visual acuity; it can also lead to improvement in vision by reducing vascular permeability, macular fluid and subretinal hemorrhage.

The advent of intravitreal anti-VEGF injections revolutionized the treatment of exudative AMD. These treatments have resulted in preservation as well as improvement in vision and quality of life.

The first anti-VEGF drug to be approved by the FDA for treating exudative AMD was pegaptanib sodium (Macugen), which is a selective inhibitor of the VEGF-165 protein. Although the effect of pegaptanib sodium on vision was only modest, it helped confirm the role of VEGF in the pathogenesis of exudative AMD and opened the door for the greater success of other antiVEGF agents. Currently, bevacizumab (Avastin), ranibizumab (Lucentis) and aflibercept (Eylea) are used as first-line therapy to treat exudative AMD. All three of these drugs are pan-VEGF-A blockers and have been shown in several clinical trials to stabilize choroidal neovascularization and vision.

The FDA has approved ranibizumab and aflibercept for treating exudative AMD. Bevacizumab is approved for treating colon cancer, but the drug is used “off label” to treat exudative AMD due to similar efficacy and a distinct pricing advantage ($50 per injection).

The pricing is higher for ranibizumab ($2,000 per injection) and aflibercept ($1,800 per injection), which reflects the FDA approval process. All three drugs are covered by Medicare, but the terms of coverage can often be complex.

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S

everal large-scale prospective studies on patients with exudative AMD have examined the efficacy of ra n ibi zu mab, a f l ibercept a nd bevacizumab. The MARINA and ANCHOR trials demonstrated that 90% of patients treated with monthly ranibizumab lost less vision over two years, and that treatment was significantly superior to prior standardof-care options, including observation or photodynamic therapy.5–7 The CATT a nd IVAN st udies demon st rated comparable efficacy and equivalent visual outcomes for bevacizumab vs. ranibizumab with monthly dosing.8,9 More recently, t he VIEW st udies showed that outcomes with aflibercept dosed every two months were clinically equivalent to monthly ranibizumab.10 Although clinical data from these trials supports anti-VEGF therapy for exudative AMD, the ideal drug choice has not been established, and treatment is often tailored to the individual patient in regards to efficacy, safety and cost.

Despite the high cost of the on-label medications, even ranibizumab (more expensive and shorter-acting than aflibercept) has been found to be costeffective in terms of quality adjusted life years.11 This benefit is due both to the importance of vision and the efficacy of the treatment.

Anti-VEGF injections are completed in the office as an outpatient procedure.

Before the procedure, anesthetic drops, pledgets and/or a subconjunctival lidocaine injection are used to numb the eye. A speculum may be used to hold the eyelids open and a povidoneiodine swab is frequently applied over the injection site. The anti-VEGF drugs are injected directly into the vitreous.

Once inside the eye, the medication diffuses throughout the retina and choroid and binds to the abnormal VEGF proteins, preventing further blood vessel growth and leakage.

Patients describe minimal discomfort with the procedure and are advised that they may see floaters immediately after the treatment for the next 1–3 days.

The risks for ocular complications following intravitreal anti-VEGF Sonoma Medicine

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Fall 2016 29

injections are low. They include endophthalmitis, non-infectious inflammation to the biologic anti-VEGF agent, retinal tear, retinal detachment, subconjunctival hemorrhage, vitreous hemorrhage, elevated intraocular pressure and traumatic cataract.12–14 The clinical trials mentioned above have not established statistically significant evidence for a greater risk of arterial thromboembolic events for patients in anti-VEGF cohorts compared with those in control

groups. Further studies are needed to better understand the potential effects of systemic VEGF inhibition.

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nti-VEGF treatment often begins w it h mont h ly i nt rav it rea l injections until the macular fluid and/or subretinal hemorrhage resolve, which is determined by optical coherence tomography imaging and fundus examination.

If the exudative features do not

continue to improve after two to four monthly treatments, switching to another anti-VEGF agent is common.

Complete resolution of exudation may not be possible for all patients, and long-term monthly treatments may be required to help maintain stability and lower the risk of further structural damage. In cases when treatment has successfully controlled neovascular activity, the injection protocols can be tailored to the individual. Treatment regimens include treat and extend (TAE) or treat as needed (PRN).

About t h ree-fourt hs of ret i na specialists in the United States treat exudative AMD with the TAE regimen.15 Once inactive disease is achieved with monthly treatment, the treatment interval is gradually extended by one to two weeks up to a maximum of 12 weeks. If disease recurs, the interval is shortened and an optimal frequency of treatment is determined to maintain disease stability.

With PRN treatment, patients are closely monitored every 4–6 weeks, and treatment occurs only with recurrence of exudative activity. PRN can increase the number of office visits and may allow for multiple recurrences before retreatment, possibly leading to disease progression and vision loss. Some patients opt for PRN because they prefer to avoid treatment when the disease is inactive. There is currently no clinical data to compare TAE and PRN approaches, but two studies have demonstrated improved visual outcomes and reduction in the number of injections and office visits from TAE regimens.16,17 Nonetheless, debates continue regarding maintenance treatment protocols for exudative AMD.

E

xudative AMD is a chronic process, and treatment is often required indefinitely. Although anti-VEGF therapies are efficacious in stabilizing AMD and optimizing visual outcomes, it is important to discuss with patients that anti-VEGF treatment is unable to cure the disease or reverse macular structural damage. For this reason, 30 Fall 2016

Sonoma Medicine

vision loss may continue to occur in patients undergoing regular treatment for AMD. It is also important to educate patients on modifiable risk factors for AMD, such as smoking, AREDS 2 vitamin supplementation, changes in diet, monitoring of visual symptoms and routine evaluations to monitor both eyes.

Significantly increased understanding of exudative activity over the past decade has translated into successful treatment regimens with anti-VEGF therapy. Future studies will help guide the use of anti-VEGF treatment in the long term and ideally lead to new therapies to prevent AMD progression.

Email: nbcvard@ubvscr.com

References

1. World Health Organization, “Global data on visual impairments 2010,” www.who. int (2012).

2. Congdon N, et al. “Causes and prevalence of visual impairment among adults in the U.S.,” Arch Ophth, 122:477-485 (2004).

3. Desai MPL, “Trends in vision and hearing among older Americans,” Aging Trends, Nat Ctr Health Stats (2001).

4. Klein R, et al, “Prevalence of age-related maculopathy,” Ophth, 99:933-943 (1992).

5. Bressler NM, et al, “Vision-related function after ranibizumab treatment by better- or worse-seeing eye,” Opth, 117:747-756e4 (2010).

6. Boyer DS, et al, “Subgroup analysis of the MARINA study of ranibizumab in neovascular age-related macular degeneration,” Ophth, 114:246-252 (2007).

7. Brown, DM, et al, “Ranibizumab vs verteporfin for neovascular AMD,” Ophth, 116:57-65e6 (2009).

8. Chakravarthy U, et al, “Ranibizumab versus bevacizumab to treat neovascular AMD,” Ophth, 119:1399-1411 (2012).

9. Martin DF, et al, “Ranibizumab and bevacizumab for neovascular MD,” Ophth, 119:1388-98 (2012).

10. Schmidt-Erfurth U, et al, “Intravitreal aflibercept injection for neovascular AMD,” Ophth, 121:193-201 (2014).

11. Brown MM, et al, “Value-based medicine analysis of ranibizumab for treatment of subfoveal neovascular macular degeneration,” Optho, 115(6):1039-1045 (2008).

12. Jager RD, et al, “Risks of intravitreous injection,” Retina, 24:676-698 (2004).

13. Moshfeghi AA, et al, “Endophthalmitis after intravitreal VEGF antagonists, Retina, 31:662-668 (2011).

14. Bakri SJ, et al, “Intraocular pressure in eyes receiving monthly ranibizumab in 2 pivotal AMD clinical trials,” Ophth, 121:1102-08 (2014).

15. “Am Soc Retina Specialists preferences and trends survey,” presented at ASRC annual meeting (2013).

16. Rayess N, et al, “Treatment outcomes after 3 years in neovascular AMD using a treat-and-extend regimen,” Am J Ophth, 1593-8 e1 (2015).

17. Arnold JJ, et al, “Two-year outcomes of treat-and-extend intravitreal therapy for neovascular AMD,” Ophth, 122:1212-19 (2015).

Sutter Medical Group of the Redwoods

A physician-owned, multi-specialty practice serving Sonoma County AFFILIATED WITH SUTTER PACIFIC MEDICAL FOUNDATION

JOB OPPORTUNITY FOR FAMILY MEDICINE AND INTERNAL MEDICINE PHYSICIANS • 1–2 years guaranteed income • Relocation allowance • Sign-on bonus negotiable • Option for shareholder track after 2 years of employment • Generous compensation and benefits • Completely ambulatory • Flexible schedule • Patient panel established within 3–6 months Please send CV to Isabelle von Tobel: vontobi@sutterhealth.org

www.sutterhealth.org

Sonoma Medicine

Fall 2016 31

SONOMA COUNTY MEDICAL

32ndAnnual

You and your spouse or guest are invited to the

A S S O C I AT I O N

Outstanding Contribution

“Celebrating exemplary service to medicine.”

TUESDAY, DECEMBER 6, 2016 VINTNER’S INN • 4350 BARNES ROAD, SANTA ROSA

Please join your colleagues in honoring the achievements of:

Jerry Minkoff, MD Outstanding Contribution to Sonoma County Medicine

Gary Barth, MD Outstanding Contribution to the Community

Rob Nied, MD Outstanding Contribution to SCMA

(To Be Announced) Article of the Year

Partnership HealthPlan Recognition of Achievement

The evening begins with a social hour at 6 p.m., followed by dinner and the awards presentation.

Dinner choices include “duet” (fish & beef) or a vegetarian dish.

Tickets for SCMA members: FREE • Spouses, guests and nonmembers: $59 each

To RSVP, or to purchase tickets:

Donations made to the Holiday

• Contact Rachel at 525-4375 or rachel@scma.org or

Greeting Card benefit the SCMA

• Send check to SCMA: 2312 Bethards Drive #6 Santa Rosa, CA 95405

Scholarship Fund. Become a

Please indicate dinner choice.

& SCMA Alliance Health Careers donor for this year’s greeting card at www.scmaa.org by Dec. 8, 2016.

GIVE-A-GIFT

Empowering Lives One Computer at a Time Laura Robertson

B

orn in California in 1994, Jeramy Lowther Jr. bounced from state to state with his single mother, finally landing in Toledo, Ohio, where he discovered that growing up without a father in the picture was rough. At 14 he moved back to Sonoma County to reunite with his father, with unfortunate results. Between his father’s issues and troubles of his own, Jeramy found himself with no stable home, no parental support and no success at school. He became homeless and entered foster care at 16.

With guidance from the VOICES Youth Center in Santa Rosa and the Valley of the Moon Children’s Home, Jeramy eventually enrolled at the Hanna Boys Center in Sonoma, a residential treatment center with an onsite high school. This event was a turning point for him. “Hanna is definitely the place that I can thank the most,” he says. “They taught me basic life skills and all the things I needed to know at my age. I started the summer before my senior year with beginning sophomore credits and was able to graduate on time with a 3.14 GPA and a couple of scholarships too. I couldn’t have done it without them.”

Ms. Robertson chairs the Give-a-Gift program for the SCMAAF.

Sonoma Medicine

laptop computers to foster youth.

“This was the nudge I needed,” recalls Jeramy, who received a laptop computer from Give-a-Gift earlier this year.

Jeremy re-enrolled at SRJC, only to discover that his homework for math class had to be completed online and that the computers in the tutorial centers were often taken. He found that owning his own computer was vital to completing this class, and to his continuing success.

Jeramy Lowther Jr. with laptop computer from Give-a-Gift.

Jeramy made more than one attempt to attend Santa Rosa Junior College, but he soon learned that taking classes without accepting necessary help was not enough to achieve success. He left SRJC, secured a safe a place to live at Tamayo Village and accepted an intern position at VOICES Youth Center. “At VOICES,” he recalls, “I saw a lot of services that people were able to get for going into school. I knew for sure that I was determined to go back into school no matter how hard it was going to be.” Thanks to the Independent Living Program run through VOICES, Jeramy learned about the Give-a-Gift program, which donates

T

he mission statement of the Sonoma County Medical Society Alliance Foundation reads, “We are physician families committed to creating a healthier Sonoma County by improving the lives of those in need.”

SCMAAF’s Give-a-Gift Program has been improving the lives of foster children in our community for more than 60 years. The program’s impact is twofold: it provides holiday gifts to meet the specific needs of youth in foster care, and it offers laptop computers to young adults who are pursuing higher education.

Removed from their homes due to abuse or neglect, foster youth often bounce from placement to placement, and they are likely to fall behind academically. Furthermore, between the ages of 18–21, foster youth “age out” Fall 2016 33

of California’s child welfare system, meaning that they are “emancipated” without any funding. Many of them never reunite with their families, so if they do reach college, it is often without parental support or long-lasting connections. Without housing, education or emotional support, their future is challenging.

By continuing their education past high school, foster youth have the best chance of success—and laptop computers are essential tools for that success.

Give-a-Gift began donating computers to local foster youth in 2007 and, with the help of its generous donor base, has since donated 15–25 computers per year. This year set a the high-water mark for donations: thirty laptops were awarded to youth attending Santa Rosa Junior College, Sonoma State University and several other schools in Nort hern California. To make these contributions go even further, the Give-a-Gift committee has partnered with Best Buy, which supports our foster yout h by discou nt i ng

computers, warranties and ongoing technical support. This year, the company also donated computer cases for all the students.

Give-a-Gift collaborates directly with the VOICES Youth Center and SRJC to identify students with the most need. VOICES (Voice our independent choices for emancipation support) is a community resource center where foster youth can access services to meet their health, wellness, employment, education and housing needs. VOICES Director Amber Twitchell observes, “Often these youth have been taught that they are worthless and that no one cares whether they succeed or fail. This program [Give-a-Gift] shows foster youth that there is a group of committed, passionate people that believe they can achieve their dreams and create a healthy life for themselves and their future children.”

W

hile Jeramy’s initial SRJC plan was to become a mechanical engineer—he thought he would build his

own robot or smart house—his focus has changed. During an internship at Sonoma Ecology Center, Jeramy developed a love of the environment. “I’m going for environmental science but want to get experience in mechanics as well,” he explains. “I want to know I can leave a mark on the world by creating a message of sustainability.”

Jeramy’s journey has had many hurdles and he’s experienced numerous setbacks, but he’s outgoing, focused, caring and very willing to share his story.

His commitment to a positive outlook has helped him excel in many ways.

Jeremy’s success doesn’t have to be unique. Empowering more foster youth to fulfill goals like his is achievable, but it requires money. Give-a-Gift is fundraising right now, and your contribution can help students like Jeramy get the laptop computers they need for success.

To donate, or to find out more about Give-a-Gift, visit scmaa.org.

Email: giveagift@scmaa.org

JOIN US!

The Sonoma County Medical Association Alliance Foundation We are a non-profit organization made up of physician families committed to creating a healthier Sonoma County by improving the lives of those in need. Our members are empowered to enact change in their own community while building a network of friendships that can last a lifetime. We invite you to become a member. Find us at www.scmaa.org.

givelaughworkshareThe SCMAAF 34 Fall 2016

Sonoma Medicine

•

N V O LV E D GET I !

•

Passport •

TO

P A R T I C I P AT I O N

•

Win an iPad through SCMA’s “Passport to Participation” To encourage physician collegiality and the advancement of community health, PASSPORT TO PARTICIPATION acknowledges Sonoma County physicians’ active engagement with SCMA, CMA and community activities by awarding points for participation.

For each participation point, your name is entered into a drawing for a chance to win an iPad. The winner will be drawn at SCMA’s Wine & Cheese Reception in May 2017. This year’s iPad winner was Dr. Rick Flinders.

Examples of how you can earn points: Be elected to the board of directors or CMA delegation.

Serve on an SCMA or CMA committee, or be a legislative advocate.

Communicate with a legislator about a health-related issue.

Participate in surveys or vote in the annual election.

Nominate a colleague for a physician award.

Attend SCMA dinner and receptions, CMA Leadership Academy or House of Delegates.

Volunteer your medical services at free clinics or health fairs.

Notify SCMA of any engagement with SCMA, CMA and/or community activity. (Submit brief description, date, number of hours, and location to SCMA.) For more details, contact Rachel Pandolfi at rachel@scma.org or 707-525-4375.

SPONSORED BY THE SONOMA COUNTY MEDICAL ASSOCIATION

MEMBERSHIP HAS ITS BENEFITS!

Free and discounted programs for SCMA/CMA members BENEFIT

PROVIDER

Auto/Homeowners Insurance Save up to 8% on insurance services

Mercury Insurance Group 888-637-2431 • www.mercuryinsurance.com/cma

Car Rental Save up to 25%

Avis or Hertz 800-786-4262 • www.cmanet.org/groupdiscounts

CME Certification Services Discounted CME certification for members

CMA’s Institute for Medical Quality 415-882-5151 / www.imq.org

HIPAA Compliance Toolkit Various discounts

PrivaPlan Associates, Inc. 877-218-7707 • www.privaplan.com

ICD-10-CM Training Deeply discounted rates on several ICD-10 solutions, including ICD-10 Code Set Boot Camps

AAPC www.cmanet.org/aapc

Insurance Services Save up to 25% on workers’ comp insurance and receive special pricing and/or enhanced coverage for life, disability, long term care, medical, dental and more

Mercer Health & Benefits Insurance Services LLC 800-842-3761 cmacounty.insurance.service@mercer.com www.CountyCMAMemberInsurance.com

Legal Services FREE access to CMA On-Call (online health law library), access to CMA legal staff through the legal information line and more

CMA’s Center for Legal Affairs 800-786-4262 • legalinfo@cmanet.org www.cmanet.org/legal

Magazine Subscriptions Save up to 50% on all subscriptions

Subscription Services, Inc. 800-289-6247 • www.cmanet.org/magazines

Medical IDs Discounts on 24-hour emergency identification and family notification services

MedicAlert 800-253-7880 • www.cmanet.org/medicalert

Medical Waste Management Save 30% or more on medical waste management and regulatory compliance services and 50% on the Compliance Portal

EnviroMerica 650-655-2045 • www.cmanet.org/enviromerica

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DocbookMD www.cmanet.org/docbookmd

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CMA’s Center for Economic Services 800-401-5911 • economicservices@cmanet.org www.cmanet.org/ces

Security Prescription Products 15% off tamper-resistant security subscription pads

RxSecurity 800-667-9723 • www.cmanet.org/rxsecurity

Webinars and Seminars CMA works with industry experts to offer timely, high-quality education programs, including FREE webinars and deep discounts on live seminars

CMA www.cmanet.org/events

PUBLICATIONS CMA Publications www.cmanet.org/news-and-events/ publications/ CMA Alert e-newsletter CMA Practice Resources

CMA Resource Library & Store www.cmanet.org/resource-library/ list?category=publications

Advance Health Care Directive Kit California Physician’s Legal Handbook Closing a Medical Practice Do Not Resuscitate Form HIPAA Compliance Online Toolkit Managed Care Contracting Toolkit Model Medical Staff Bylaws Patient-Physician Arbitration Agreements Physicians Orders for Life Sustaining Treatment Kit

SCMA Publications www.scma.org Sonoma Medicine (quarterly) Sonoma County Physician Directory (annual) SCMA News Briefs (monthly)

CONTACT SCMA/CMA: 707-525-4375 • scma@scma.org

36 Fall 2016

September 2016

Sonoma Medicine

CURRENT BOOKS

Boo Radley, Block Parties and World Peace Brien A. Seeley, MD

Connectography: Mapping the Future of Global Civilization, Parag Khanna, Random House, 496 pages (2016).

The absent are always in the wrong.

—English proverb

C

all him Mr. Miller. Like Boo Radley in To Kill A Mockingbird, he was our neighborhood’s reclusive boogeyman. As kids in the early 1950s, we one-upped each other’s scary tales about how the raging Mr. Miller might suddenly burst out of his side door to chase any kid who dared to take the shortcut across his scruffy unmowed lawn. When we played in the street, fetching the errant ball from his yard made the hair stand up on the back of our necks. Some said that he was always in there lurking, ever watching from behind his dark windows. Some said he collected swords and spears. He never had visitors. Mom said that was because he “probably has something wrong with him.” He rarely came outside, but when he did, he always wore a dark suit, like an undertaker, and would rush to get in his car and drive off into the night.

For years, the spooky Mr. Miller was ostracized, and his overgrown hermitage was off-limits to all the peace-loving Dr. Seeley, a Santa Rosa ophthalmologist, serves on the SCMA Editorial Board.

Sonoma Medicine

postwar families living on our street in Manhattan Beach, a Los Angeles suburb. Our neighborhood was doubly cursed—Mr. Miller with isolation, and the neighbors with ongoing fear of the “unknown other”—until that fateful Saturday, 1956, at our annual St. Patrick’s Day potluck block party.

We were shocked to see Mr. Miller show up. Who had invited him? He wore a dark suit and tie and was accompanied by a cheerful woman named Tarja. He was smiling and pleasant to everyone, and we kids finally got to see him up close. He had brought Rumaki (baconwrapped water chestnuts), a treat that he had discovered while stationed in the South Pacific during the war. In a gentle Irish brogue, he regaled everyone with his life story. He had lived in England, but his wife had been killed during

the Blitz and in his grief he left for the U.S., where he enlisted right after Pearl Harbor. He was seriously wounded in the Solomon Islands and was sent home.

After the war, he was mired for several years in lonely depression, but he found a rebirth by taking up ballroom dancing at the Aragon Ballroom in Santa Monica. There, he met Tarja, who was from Finland and loved to dance. Our mythic boogeyman had co-founded the Aragon Dance Studio, where he usually worked until 2 a.m. Consequently, he had to sleep past noon on most days.

From that day forward, Mr. Miller and his Rumaki were always welcomed at the block parties. He told us kids we could take the shortcut through his yard any day, as long as we were quiet. He even hired my big brother Mark to mow his lawn. Several neighbors enrolled at his dance studio. A new age of harmony, peace and prosperity came to our block.

T

he revival of Mr. Miller and the rejuvenation of our neighborhood is a fitting allegory for Connectography, Parag Khanna’s book about new ways to create world peace, harmony and prosperity. Khanna suggests that international “bloc parties” could build prosperous new trade groups like the EU that could peacefully unite all of the Americas or all of Asia in new, win-win relationships. To ensure peace, such blocs would need to include rogue Fall 2016 37

nations such as Cuba and North Korea that, like Mr. Miller, are mistrusted.

This new paradigm would replace nationalistic geopolitics with blocs made of networked “nodes” that could be city states, mega-regions or small nations.

These blocs, Khanna claims, would evolve efficient, shared, interdependent supply chains that would transcend sovereign borders. By being intricately connected in trade, transportation and culture with both their own member states and the other major blocs, the blocs would be motivated to settle differences peacefully.

Khanna supports his views with examples that are enlivened by his astute explanation of the principle each one embodies. Some of these principles are familiar from the saga of Mr. Miller: Sanctions cause nations to find partners elsewhere (like Tarja); trade with far-off places brings new culture and products (like Rumaki); trust in neighbors opens new opportunities (like shortcuts, jobs and dance classes).

Khanna refers to this connectivity as a “supply chain world.”

[A] supply chai n world is a postideolog ical la ndscape. Russia no longer exports communism; America scarcely proffers democracy; China has abandoned Maoism for hyper-capitalist consumerism. From Africa to Asia—the lion’s share of the world’s population— it’s all business, all the time.

He sees large investment by both nations and multinational corporations in infrastructure connections and the resulting supply chains as a tide that will raise all boats. He goes on to predict that the resulting relationships and prosperity will likely make future wars an untenable option and will produce the growth in productivity, education, and sustainability that will be needed on a planet with nearly 8 billion people.

Investors, nations and corporations will continue to be the main winners: the 1%.

But Khanna sees the 99% as having a new and powerful borderless proletarian leverage in being able to disrupt crucial supply chains rather than protesting to gridlocked governments. He says the World Trade Organization and new 38 Fall 2016

supply chain governance entities, such as the Extractive Industries Transparency Initiative, will also help implement environmentally mindful management of the extraction of shared resources, a control that is essential to avoiding a tragedy of the commons.

A

ttempting to isolate any nation— whether by sanctions, embargos or blockades—has proven to be largely futile and unwise, says Khanna. He explains how Russia, Iran and North Korea have all made effective end-runs around the sanctions enacted against them. History has repeatedly shown that seeking security or exclusive privilege behind a fortress wall actually cements that place as one to be resented, climbed over (the Alamo), tunneled under (Gaza Strip), torn down (Berlin) or placed under siege (Troy). Those who hide behind walls become the most vulnerable to siege.

In today’s world, secrets are hard to keep, says Khanna. Ubiquitous satellite imagery, video surveillance, social networks and the internet act like evervigilant “eyes on the street.” Intelligence, shipping and trade networks furnish nearly instantaneous tracking of where natural resources are going. These new forms of connectivity help stabilize world peace. The flow of oil resources and its price, for example, is tracked daily if not hourly. Strategies such as the radio silence used by the Japanese fleet in its surprise attack on Pearl Harbor are now anachronistic. Today the immediate detection of expansionist aggression enables prompt countering moves that render such aggression futile. As modern nations increasingly recognize that locally produced renewable energy can replace their addiction to imported fossil fuel, the likelihood of resource wars diminishes, according to Khanna.

To impute evil intent from the unknown other encourages military build-ups and the building of walls rather than productive connections, says Khanna. Vilifying the unknown other is the strategy that empowers despots and that impels people to act in fear or anger rather than with wisdom. In contrast,

connecting with the unknown other, such as Mr. Miller, can result in mutually beneficial trade and help ensure peace and prosperity.

Connectography is America-centric in its outlook, and it holds up a mirror to U.S. policymakers: America is increasingly divided between its key global nodes and its Rust Belt backwaters. Already it is inaccurate to think of America as “united” when in fact Americans belong—or don’t belong—to vastly different global supply chain circuits. The divides are not just red state versus blue state but urban versus rural. Voter preferences align much more according to professional circuits—factory worker, teacher ma nagement con su lta nt, ba n ker, farmer—than to geography.

Khanna goes on to quote urban expert Richard Longworth: Midwestern states make no sense as units of government because, for example, Kansas and Missouri battle to get companies to relocate across State Line Road rather than uniting against global competition.

M

ak ing large invest ments in bot h domest ic a nd foreig n infrastructure in the form of highways, bridges, tunnels, canals, pipelines, container seaports and rail lines is the author’s recommended strategy for modern nations. Such “checkbook diplomacy,” Khanna repeatedly points out, is how China is rapidly establishing access to resources in Africa, South Asia, South America, Russia and Eastern Europe. Exporting construction services in exchange for millions of tons of raw materials is making China the new symbiotic partner of many undeveloped countries. This effective and peaceful way toward national security contrasts starkly with the enormous military spending by the U.S. for “deterrence” and homeland security. Positioning the U.S. for world domination in military power ignores history. “Deterrence massively raises the stakes of conflict,” says Khanna. Founded upon a hubris born of militar y superiorit y, t he Sonoma Medicine

strategies of “shock and awe,” “surge” and “blitzkrieg” have all failed to achieve their ultimate objectives.

During World War II, U.S. military spending was $4.1 trillion in 2011 dollars, and 60 million lives were lost across the globe.1,2 In the last four years, the U.S. has spent roughly $2.4 trillion on its military. Khanna says some of these funds could be better spent to create new infrastructure around the world that would strengthen U.S. supply chains and peaceful relationships. He beseeches the U.S. to wake up and amend its ways, and he posits that if all the global superpowers achieve selfsufficiency through peaceful, transparent and open trade, then détente will be automatic. Wars will simply be too expensive.

I find two faults with this book.

Khanna treats climate change as if it were a mere rival of global resource development rather than as the existential threat that it is. He also fails to adequately address the two historically untamable threats to peace: religious zeal and population growth. If we are to ensure world peace for our grandchildren, we will need more than improved connectivity to tame these two threats.

Khanna concludes Connectography with this observation: When resources are widely distributed, governments are less likely to fear being cut off from access to precious raw materials, and thus to fight over them.

There is no more need for resource wars. . . . But if we want to enjoy the benefits of a borderless world, we have to build it first. Our fate hangs in the balance.

I urge everyone to read Connectography. If offers an important and comprehensive new perspective on current world affairs.

Email: brienseeley@gmail.com

References

1. National World War II Museum, “By the numbers: world-wide deaths,” www. nationalww2museum.org (2016).

2. Congressional Research Service, “Costs of major U.S. wars,” fpc.state.gov (2008).

Sonoma Medicine

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Tinnitus Care Program People suffering from tinnitus may experience whistling, hissing, buzzing, ringing or pulsing in the ear that persists even in the absence of external sound. Audiology Associates’ comprehensive Tinnitus Care Program provides the most advanced diagnostics and treatments available to help patients manage this condition.

hear today, hear tomorrow Peter J. Marincovich, Ph.D., CCC-A Director, Audiology Services

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Amber Powner, Au.D., CCC-A Clinical Audiologist

MENDOCINO (707) 937-4667

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Fall 2016 39

REASONS

TOP

To Join SCMA and CMA

COMMITMENT TO THE PROFESSION

Working together, the Sonoma County Medical Association and the California Medical Association are strong advocates for all physicians and for the profession of medicine. Of the many reasons for joining SCMA and CMA, 10 stand out:

PRESERVING MEDICARE

By joining SCMA and CMA, physicians affirm their commitment to the profession of medicine and to preserving its honored place in modern society.

Thanks to SCMA, CMA and other medical associations, recent attempts in Congress to cut the Medicare reimbursement rate have all been rebuffed.

IMPROVING COMMUNITY HEALTH

PROTECTING MICRA

SCMA is involved in several initiatives to improve community health in Sonoma County, such as increasing access for the uninsured and bolstering primary care.

LEGISLATIVE ADVOCACY

SCMA and CMA work diligently to protect the Medical Injury Compensation Reform Act (MICRA), which safeguards low liability insurance rates for California physicians.

PRACTICE MANAGEMENT

By speaking with a united voice, SCMA/CMA members exert a powerful influence on the political process at the local, state and national levels.

SCMA and CMA offer a wealth of resources to help physicians manage their practices, implement electronic medical records and qualify for federal incentive payments.

FOSTERING COLLEGIALITY

STAYING IN TOUCH

SCMA and CMA bring doctors from all parts of the medical community together—through leadership, cooperation and social gatherings.

Through their magazines, newsletters and websites, SCMA and CMA encourage physicians to stay in touch with each other and with current medical news and events.

FREE MEDICAL-LEGAL INFORMATION

IT’S EASY AND FUN

CMA offers free medical-legal information on contracts, subpoenas, employee relations, collections and many other topics.

ASK YOUR COLLEAGUES ABOUT SCMA AND CMA

To join SCMA and CMA, go to www.cmanet.org/join.

Once you belong, it’s fun to get involved in medical society projects and events.

One of the best ways to learn more about the benefits of membership in SCMA and CMA is to ask your colleagues. The physicians listed below have leadership roles at SCMA and would be happy to take your call.

President Regina Sullivan, MD Obstetrics & Gynecology 707-393-4000 regina.t.sullivan@kp.org

Secretary Patricia May, MD Surgery 707-393-4000 patricia.e.may@kp.org

President-Elect Peter Sybert, MD Anesthesiology 707-522-1800 pessramg@aol.com

Board Representative James Pyskaty, MD Pediatrics 707-393-4000 ym4djp@gmail.com

Treasurer Brad Drexler, MD Obstetrics & Gynecology 707-431-8843 b9drexler@gmail.com

Immediate Past President Mary Maddux-González, MD Family Medicine 707-285-2970 mmgonzalez@rchc.net

RIGHT NOW is the best time to join SCMA and CMA. Contact Rachel Pandolfi at SCMA 707-525-4375 or rachel@scma.org.

–OR–

Join online at www.cmanet.org/join

NEW MEMBERS

PERSONAL HISTORY

INDEPENDENT

Stephen Lee, MD, Nephrology, 435 Doyle Park Dr., Santa Rosa, Boston Univ 2011 Anish Shah, MD, Psychiatry, 1260 N. Dutton Ave. #275, Santa Rosa, Sarda Patel Med Coll 1996 David Southwick, MD, Undersea & Hyperbaric Medicine, Wound Care, Santa Rosa, Univ Health Sci 1981 ST. JOSEPH HEALTH MEDICAL GROUP

Michael Rosedale, DO, Family Medicine*, 500 Doyle Park Dr. #G04, Santa Rosa, Western Univ 2008 THE PERMANENTE MEDICAL GROUP

401 Bicentennial Way, Santa Rosa Alejandro Casillas, MD, Emergency Medicine, Univ Southern California 2008 Douglas Green, MD, Vascular Surgery*, Harvard Med Sch 1997 Eiman Jahangir, MD, Cardiovascular Disease, Univ Tennessee 2005 Mark McManigle, DO, Family Medicine*, Coll Osteo Med Pacific 1998 Christopher Styles, MD, Emergency Medicine, St. Louis Univ 2013 Patrick Wuthrich, DO, Emergency Medicine, Touro Univ 2012 * board certified italics = special medical interest

CLASSIFIED Medical weight-loss practice / Fall in love with practicing medicine again Proven, highly recognized and profitable, established weight-loss practice in beautiful Marin County. Current multiple 6 figures, room for expansion. Work-life balance, time freedom, financial security, relationship-driven practice.

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Subterranean Homesick Bells Rick Flinders, MD

I

don’t know about you, but I found kindergarten to be a jarring and unexpected interruption of my chosen lifestyle. At two I’d discovered I was an autonomous being. By three I was pretty much master of my own domain. At four I had settled into a perfect work-life balance. I played, I explored, I discovered. When I was hungry, I ate. When I got tired, I went to sleep. But then, at five, my mom told me I had to go to kindergarten.

Every morning I was awakened by a truly alarming bell from my alarm clock. I couldn’t wear my jeans or T-shirt. Instead, I had to put on terribly brown corduroy pants and wait outside our house for a bus. But the worst part was—get this—I couldn’t even take my dog. Where the hell was I going? The bus was big and yellow and full of yapping kids, and it dropped us off at school where, guess what, there were more bells.

Bell rings, we go into class. Bell rings, we go out to recess. Bell rings, we go back to class. Bell rings, we have graham crackers and milk. Bell rings, we lie down on our mats. Bell rings, we get back on the bus and go home. Try explaining this to your dog.

“Don’t worry,” I told her, “they said it’ll be over in June.”

And they were right. But what they didn’t say was that in September we had to do it all over again.

“What for?” I asked.

“First grade,” they said.

“Well, how many of these ARE there?”

“Eight.”

“EIGHT?!” I cried. “Then what?”

“Well, four of high school . . . then four of college . . . and, if you want to be anything special, probably four more, but you don’t get your summers off. And if you want to be a speciaLIST, it’s another three to five . . . ” You know the rest. Twenty years of schooling and they put you on the day shift. (Some nights, too.) Way I figure it, I’ve been answering that bell now for 65 years, ever since I was five years old. And all that bell’s modern progeny: phones, sirens, beepers, alarms, ring tones, pagers and notifications. But I’m not complaining. Mostly, I feel grateful for the privilege and the adventure, of getting to do what I’ve done.

But now . . . I look forward to my earlier way of life . . . with a little more wisdom, a little more freedom to choose my own work, at my own pace. Without the hurry, without the worry . . . and certainly without the bells.

Email: rickflinder@gmail.com Dr. Flinders, inpatient director of the Santa Rosa Family Medicine Residency Program, serves on the SCMA Editorial Board.

Fall 2016 41

practice practice manager’s manager’s Forum Forum practice manager’s Forum A LOCAL NETWORK FOR SCMA/CMA MEMBERS AND THEIR STAFF

~A ~AFREE FREE Lunch Lunch &&Learn Learn Seminar*~ Seminar*~ ~A FREE Lunch & Learn Seminar*~

Contract Contract Negotiations: Negotiations: Contract Negotiations: Seeking strategies for your practice

to become or remain competitive in“NO” today’sWith marketplace How How To ToTo Get Get Past Past “NO” “NO” With aa Payor Payor How Get Past With a Payor Free

Thursday, September September 8, 8,2016 2016 Thursday, September 8, 2016 Join SCMA’s Thursday, NEW — a.m. a.m.

––development 11–p.m. p.m.

11:30 a.m.

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and solutions to challenges that come with managing an independent practice.

Vista Vista Family Family Health Health Center, Center, Conference Conference Rooms Rooms AA&&A BB& B Vista Family Health Center, Conference Rooms

Many independent practices are thriving today, despite challenges posed by health care

3569 3569 Round Round Barn Barn Circle, Circle, Santa Santa Rosa Rosa 3569 Round Barn Circle, Santa Rosa

delivery reforms. Equipped with basic business knowledge and skills, physicians are demonstrating that it is still possible to have a successful and rewarding private practice.

Some ~ are ~~Complimentary Complimentary lunch lunch will willbe be provided. provided. ~ even ~ Complimentary lunch will be provided. ~ opening new solo and small group independent practices.

The Practice Managers Forum (PMF) offers a wide array of activities and access to information covering LUNCH LUNCH &&LeARN LeARN LUNCH & LeARN hensubmitting submitting aarequest request totoopen open aacontract contract renegotiation renegotiation hen submitting a request to open a contract renegotiation issueshen and areas of common interest.

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Failure CMALegal: Legal: NewLaws Laws for for CMA New Legal: Newfor Laws Specially designed seminars and workshops, featuring the Lunch Learn series and other 2017 2017 &2017 &How How They Will present present business case caseoften oftenoften results results ininaaquick quick reply replyreply from fromfrom the thepayor payor &They HowWill They Will • aabusiness present a business case results in a quick the&payor Affect AffectYour YourPractice Practice Affect Your Practice Essentials forare Independent indicating indicating that thatthey they arenot not aaposition position totoseminars. renegotiate renegotiate atatthis this time.time. indicating that they areinin not inPractice a position to renegotiate attime. this January/February January/February 2017 20172017 January/February Join Joinus ustotolearn how howto toprevent prevent the the“auto~reply” “auto~reply” and andtoto create create and and and Join uslearn to learn how to prevent the “auto~reply” and to create Medicare Medicare Changes Changes Medicare Changes Direct access to valuable information: • submit submit aathoughtful thoughtful renegotiation renegotiation request. request. submit a thoughtful renegotiation request.

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Fax: Fax:707-525-4328 707-525-4328 • •email: email: rachel@scma.org rachel@scma.org Fax: 707-525-4328 • email: rachel@scma.org Mail: Mail:sCMa, sCMa, 2312 2312bethards bethards Dr. Dr.#6, #6, santa santa Rosa Rosa95405 95405 Mail: sCMa, 2312 bethards Dr. #6, santa Rosa 95405

Accounts AccountsReceivable Receivable

CMA’s Center for EconomicAccounts Services,Receivable including a toll-free helpline for assistance with reimbursement and contracting matters.

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CMA Practice Resources (CPR), a free Getting Getting Paid: Paid:APaid: APhysician’s Physician’s Getting A Physician’s monthly e-mail bulletin with tips tools.

Guide Guide To ToTaking Taking Charge Charge ofof of Guide To and Taking Charge

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CMA Resource Library & Store of publications; webinars; and downloads of timely Name Name_______________________________________________________________ _______________________________________________________________ Name _______________________________________________________________ topics such as payor profiles, Medicare Phone Phone____________________ ____________________ Email Email_______________________ _______________________ Fax Fax____________________ ____________________ Phone ____________________ Email _______________________ Fax ____________________ Rnew a a quality reporting programs,R eRand e eeS See n i na emiSni e em m Practice Practice name name and and address address ___________________________________________________________ ___________________________________________________________ Practice name and address ___________________________________________________________ tobacco products.

__________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ hhPhysician hhOffice hhOther become PMF member, just send________________________________________________________________ your name, title, phone and email address (and if you’re Physician Office Manager Other ________________________________________________________________ hTo haManager h________________________________________________________________ Physician Office Manager Other not a physician, the name of the physician you work with) to Rachel Pandolfi at rachel@scma.org.

Questions?

Questions?

Contact Contact Rachel Rachel Pandolfi Pandolfi atat707-525-4375 707-525-4375 ororrachel@scma.org. rachel@scma.org.

Questions?

Contact Rachel Pandolfi at 707-525-4375 or rachel@scma.org.

Questions? Call Rachel at 707-525-4375.

The The quarterly quarterly PMF PMF Lunch Lunch & & Learn Learn seminars seminars offer offer attendees attendees a a broad broad array array ofof topics topics relatedto tomedical medical staff staffservices, services, office officemanagement, management, The quarterly PMF Lunch & Learn seminars offer attendees a broad array ofrelated topics related to medical staff services, office management, ** * billing billingand andcoding, coding, human humanresources, resources, accounting accounting and andback back office office support.

Nonmembers, Nonmembers, and/or and/ortheir theirstaff, staff, are are welcome welcome totoattend attend aseminar seminar billing and coding, human resources, accounting and backsupport. office support.

Nonmembers, and/or their staff, are welcome toaattend a seminar atatnonocost cost to to experience experience one one of of the the many many valuable valuable benefits benefits that that come come with with SCMA SCMA membership membership ($25 ($25 thereafter). thereafter). at no cost to experience one of the many valuable benefits that come with SCMA membership ($25 thereafter).

Connect and communicate with your colleagues!

Lunch & Learn Seminar NewLaws Lawsforfor2017 2017 New

HowThey TheyWillWillImpact ImpactYour YourPractice Practice andandHow Wednesday, Nov. 2016 Wednesday, Nov. 2, 2, 2016 11:30 a.m.

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ARE YOU ARE YOU READING CPR? READING CPR?

CPR containsthe the latest latest in CPR contains in Practice PracticeManagement Management Resources, Updates and CPR contains the latest in Resources, Updates andInformation.

Information.

Practice Management Resources, Updates and Information.

CMA Practice Resources (CPR) May 2012

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In this issue:

Aetna to require additional May 2012

accreditation requireMay 2012 ments in order to be paid for certain surgical

is a free monthly e-mail bulletin from CMA’s Center for Economic Services. This bulletin is full of tips and tools to help physicians and their office staff improve practice efficiency and viability. pathology services

1 Inthis this e: Update issue: on two Anthem Blue n requireissu Cross issues pending ditatio InAetna with the additi onal accre al Department

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Partnership HealthPlan Tesconi Circle, Santa Rosa, CA 95401 Santa Rosa 495 location to be announced $20 registration fee includes complimentary lunch

ts requiremen reditation itional acc gical pathology serAetna req uire addadditio sur itation to to require nal ainaccred Aetinnaorder requirements to paid for cert order to bebe paid for certain surgical pathology serinvices vices

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Contact Rachel Pandolfi at Contact Rachel Pandolfi at707-525-4375 707-525-4375or orrachel@scma.org rachel@scma.org Pleasehelp helpus usprioritize prioritizespeakers speakersfor forfuture futurelunch lunchand anddinner dinnerprograms programsby bychecking checking Please your top five topics of interest: your top five topics of interest: ___ Analyzing Analyzing your your managed managed care care contracts contracts Avoiding and preventing embezzlement ___ Avoiding and preventing embezzlement ___ Customer Customer service service successful successful practice practice Fundamentals for practice ___ Fundamentals for practice managers managers ___ Getting Getting paid: paid: aa physician’s physician’s guide guide to to taking taking charge charge of of accounts accounts receivable receivable How it’s being done: successful solo practices in 2016 ___ How it’s being done: successful solo practices in 2016 ___ How How to to reduce reduce medical medical practice practice overhead overhead ___ Knowing Knowing your your options: options: benefits benefits of of merging, merging, buying, buying, selling, selling, and and other other strategies strategies ees and and reducing reducing confl conflict ___ Managing Managing difficult difficult employ employees ict ___ Managing Managing up: up: masterful masterful management management for for your your physicians physicians Managing your online presence ___ Managing your online presence ___ MBA MBA for for MDs MDs and and managers managers (three-part (three-part series) series) Medicare changes for 2017 ___ Medicare changes for 2017 ___ Re/negotiating Re/negotiating PPO PPO contracts contracts ___ Reducing Reducing overhead overhead and and increasing increasing profitability profitability ___ Survival Survival skills skills to to thrive thrive in in independent independent practice practice ___ Tips Tips to to avoid avoid practice practice management management hypertension hypertension

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Fall 2016 43

WORKING FOR YOU

Your Voice for Change Regina Sullivan, MD

H

ere’s a ques• SCMA advocates SCMA Membership tion I like for improved access to PRACTICE TYPE Physicians SCMA % to ask my care for all local resiSolo Practice 261 85 33% colleag ues when dents and participates Small and Medium Groups (2–10 physicians) 122 32 26% I’m speaking about in health access proLarge Groups (>10 physicians)

709 476

67% membership in the grams with commuSonoma County Medinity partners such as Total 1092 593 54% cal Association: Are Covered Sonoma and LARGE GROUP MEMBERSHIP you satisfied with the the Specialty Access Analgesia & Anesthesia Medical Group 39 3 8% frequently changing Improvement Project.

Community Health Centers/Government 47 10 21% rules and regulations • CMA’s reimbursNorthern California Medical Associates 37 26 70% made by non-physime nt e x p er t s h ave Redwood Radiology Group 15 15 100% cians governing your recouped $10 million St. Joseph Health Medical Group 87 54 62% career in medicine? from payors on behalf Santa Rosa Memorial Hospital 17 1 6% I f yo u r a n s we r i s of physician members Sutter Family Medicine Residency 48 42 88% a ny t h i ng besides over the past five years.

Sutter Medical Group of the Redwoods 81 19 23% YES!, I then ask what • SCMA a nd CMA The Permanente Medical Group 338 306 91% would you change to work diligently to proincrease your satisfactect the Medical Injury tion? What are your Compensation Reform ideas, solutions or recommendations? makers. SCMA has been there for us to Act (MICRA) and spearheaded a sucNext, how would you go about making do just that. It’s our voice in medicine in cessful campaign to defeat the antithose changes? Where would you start?

Sonoma County and, through the Cali- MICRA Prop 46 in the 2014 election.

You’re just one person, one voice. fornia Medical Association, the entire • CMA’s professional economic advoWhen you join SCMA, your voice state of California. cates and practice-management experts gets amplified and becomes a strong As shown by the accompanying offer free one-on-one small-practice catalyst for change. You can bring your table, 54% of the practicing physicians resources, such as complying with ideas to a forum of your peers—other in Sonoma County already belong to regulations, analyzing contracts and doctors just like you and me—and SCMA, but we have plenty of room to billing, and helping with payment contribute to making positive improve- grow. Our goal is to increase member- problems. They’re on-call at 800-786ments to our profession and to the health ship to 60% by next summer.

4262. of our patients.

If you’d like to join SCMA and CMA, • CMA and SCMA are advocating for We practice medicine to deliver here are just a few of the many benefits several 2016 ballot initiatives, includquality health care to our patients. We of membership: ing increasing California’s tobacco tax understand our patients’ needs, and we • SCMA is involved in several initia- (Prop 56) and reducing gun violence advocate for them every day. Yet when tives to improve community health in (Prop 63). it comes to the leadership in health care, Sonoma County, including Sonoma Join your voice with those of your we often bury our heads in our charts Health Action, the Committee for colleagues. Our collective voice is signifand leave it to someone else. To foster Health Care Improvement, the My Plan/ icantly more powerful than a single one. change, to have our voices heard, we My Care advance directives project, the You can make a difference. Rediscover need to sit at the table with the decision Hearts of Sonoma CVD risk-reduction your passion: Your patients and your program, anti-tobacco efforts, oral profession will thank you!

Dr. Sullivan, an ob-gyn at Kaiser Permanente health initiatives, safe prescribing of Santa Rosa, is president of SCMA. opiates, and much more.

Email: regina.t.sullivan@kp.org

44 Fall 2016

Sonoma Medicine

Same doctors.

Same office.

New name.

Annadel Medical Group and Queen of the Valley Medical Associates are now St. Joseph Health Medical Group. We remain committed to keeping this local community healthy, and that’s something that will never change. Come experience the same exceptional doctors and quality patient experiences you know and trust. The only thing that’s new is our name.

Dignity + Service + Excellence + Justice

Learn more about St. Joseph Health Medical Group and find the right doctor for you or your family at StJosephHealthMedicalGroup.com

Finding the right surgeon shouldn’t be a pain.

Our specialists use the region’s only robotic-assisted technologies, such as the daVinci Xi® and MAKO® surgical systems, for your optimal recovery. Minimally invasive surgery often results in fewer complications, smaller scars and less pain.

Find the right surgeon at sutterpacific.org/surgery